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Governance Unit: Accreditation Cycle Management

Accreditation Cycle Management guides the 1095 Strong journey

Accreditation Cycle Management (ACMC) heightens focus on the entire accreditation process that enables increased intracycle client accountability and policy consistency across all AAAHC accreditation and certification programs.

Reports to Board of Directors

Activities and responsibilities

  • Periodically review accreditation and certification cycle policies including eligibility, survey process and appeals process.
  • Serve as a resource to staff to assist in evaluating more complex regulatory agency rules and examine impact on AAAHC accreditation survey policies, process and decisions (e.g., CMS certification termination notifications with consideration for risk).
  • Define and monitor the appeals process; note that day to day appeals management is handled by the Accreditation Committee in coordination with Staff.
  • Provide input to intra-cycle activities (e.g., annual attestation, adverse event reporting requirements).
  • Collaborate with staff to establish and monitor a process for conducting validation surveys for which feedback on the effectiveness of surveyor assignments, education and other program initiatives could be assessed and serve as input for program improvement.
  • Monitor CMS state agency validation surveys for discrepancies with findings, identifying trends and providing recommendations to inform accreditation/certification processes, Standards development or surveyor education.
  • Provide input to development of the client education curriculum based on program changes, needs assessments and program evaluation data.
  • Assist staff in establishing criteria for intra-cycle changes that warrant additional information and/or onsite surveys.
  • Consider client needs based on marketing feedback and other research.
  • Comply with all Governance Unit and AAAHC policies.
Composition, Expertise or Experience Required
  • Interest in promoting quality in ambulatory care with ability to think beyond a single specialty or ambulatory setting type.
  • Professional experience in an ambulatory health care setting. Technical or clinical expertise in a clinical specialty.
  • AAAHC surveyor experience preferred, but not required.
Benefits of Membership
  • Contribute to the improvement of ambulatory care quality and patient outcomes.

See our Governance Unit Application Process here


Annual Time Commitment Requirements

Activity# Per YearDurationDay/TimeLocation
Face-to-face meetings1-20.5-1.0 daysVariableVariable
Conference calls6-81.0-1.5 hrsEvenings
Hours/year of committee work required outside of meetings/calls10-20Additional travel or time commitmentsNone

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Achieving Accreditation

Strengthen your accreditation readiness

Achieving Accreditation (AA) is an interactive, immersive event designed to help you learn and prepare for your AAAHC survey while developing a deeper understanding of AAAHC Standards. We are facing the future together…1095 Strong!

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Kershner Quality Improvement Award

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Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space.

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