Are all Accrediting Organizations the Same?

Medical Staff Services, AccreditingLike any competitive organization, the what, when and how services are delivered can mean a big difference in how you perform. Every organization carrying the Centers for Medicare & Medicaid Services (CMS) moniker “Approved Accrediting Organization” has worked through a rigorous process to document their rules and regulations will be followed by hospitals they accredit. The question remains, what does that really mean to you and your hospital? Yes, the partner you’ve selected has been approved to perform surveys and work with you to correct any wrongdoings, but how they go about their day to day operations can be disparately different.

As your organization works through the process of choosing a survey partner, or better yet as your organization works through the process to change survey partners, what should you be looking for? After all, this is your opportunity to ask “What will your accrediting organization do to help support us in meeting the Conditions of Participation for Acute Care Hospitals as well as our own internal regulations?”

Other considerations:

  • What types of surveys are conducted?

  • Is there a requirement for an annual self-assessment?

  • Other than a triennial survey, how often are other required surveys conducted?

  • Are additional fees attached to “complaint” or “follow-up” surveys to clear condition level findings?

  • Is the Accreditation Outcome simple or complex? Do you get a Pass/ Fail or are there complex rules?

  • What’s their time frame for submitting a “Plan of Correction” following a survey? If the data has been collected and the survey is complete, you don’t want to wait for a plan, you want to get the plan and strike while the iron’s hot!

  • Does the Accrediting Organization charge extra for these important components:

    • Standards interpretation?

    • On-line access to standards?

    • Audio conferences to educate staff and leadership?

    • Resource and reference libraries with tools to aid compliance?

Choosing a partner as your Accrediting Organization can be a challenging task. Colleagues within your healthcare organization may have heard of this one or that one and may simply be comfortable partnering on name alone. Your responsibility in choosing a partner to meet internal and CMS standards is to vet appropriately, thoroughly, ask hard questions and ensure the partner you choose is there to support you and not just provide a shiny plaque to hang on the wall.

Payor Enrollment


Jim Leonard

About the Author
Jim Leonard

Jim serves symplr as the business development leader of Provider Management and Payor Enrollment. He brings more than 20 years of highly successful sales, marketing and consulting leadership to symplr. His team’s focus is to aid clients with the identification and resolution of gaps in current credentialing, privileging, peer review, quality, and event reporting programs. Jim’s insight into utilizing technology to create transparency and improve operational efficiency promotes overall improvement in provider and hospital performance; further aiding clients in meeting or exceeding compliance with governing body requirements such as CMS, JC, DNV, and CIHQ.

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