Additional Information
Frequently Asked Questions
Who is the Center for Improvement in Healthcare Quality (CIHQ)?
CIHQ is a privately-held company established in 1999 and headquartered in Mexia, TX. We provide accreditation services to hundreds or hospitals and other healthcare entities across the United States Puerto Rico and Guam.
What accreditation program(s) have been approved by CMS?
CIHQ has been granted deeming authority by CMS for our our hospital, critical access hospital and acute psychiatric hospital accreditation program. CIHQ is the nation’s 4th accrediting provider, joining the Joint Commission, DNV, and HFAP.
What is a “deeming authority”?
In order for a hospital to participate in the Medicare program, it must either be certified directly by CMS or be accredited by an organization whose standards and survey procedures have been “deemed” by CMS to meet Medicare requirements. Such organizations then have “deeming authority” by CMS.
Does this mean that CIHQ can accredit a hospital for Medicare participation like the other accreditation providers do?
Yes! A hospital can use our accreditation to meet applicable requirements for participation in the Medicare program.
Can our hospital be accredited by CIHQ without having to participate in Medicare?
Yes, a hospital can be accredited without needing to participate in Medicare. Many hospitals choose this option to satisfy State licensure requirements and/or insurance company contracting requirements.
What are CIHQ’ standards based on?
Our standards are based on the Medicare Conditions of Participation (COP) for Hospitals. The specific requirements under each standard are based on the interpretive guidelines of the COP published by CMS in their State Operations Manual (SOM).
Since the fundamental responsibility of a deeming authority is to assure that a hospital meets the Medicare COP’s, it makes sense to assure that our standards are consistent with those regulations.
In addition, having our requirements based on the interpretive guidelines by CMS will assure that your compliance to our standards will translate into your compliance with CMS requirements.
Does CIHQ have any standards in addition to the COP’s?
Yes, we have developed a reasonable and modest set of additional standards to address gaps in the COP’s in the areas of patient safety and quality care. We have been very careful, however, to remember that our primary purpose is to deem hospitals as being in compliance with the Medicare COP’s so they can participate in the Medicare reimbursement program – not add additional burdens on them.
What is the scope of CIHQ’ accreditation program?
CIHQ will survey and accredit all services and sites of care listed on the hospital’s license (if applicable) and billed under the hospital’s Medicare certification number (CCN).
My hospital has home health and long-term care services. Our current accreditation provider requires us to have these programs surveyed because the hospital is surveyed. Will CIHQ require this?
No. CIHQ will not require other components of a healthcare organization to be surveyed just because the hospital is seeking accreditation. CIHQ will only survey those services and sites of care on the hospital’s license and billed under the hospital’s Medicare number.
Will CIHQ survey contract services?
Yes, CIHQ will survey contract services provided on behalf of the hospital that are performed in the hospital.
Will CIHQ recognize other accreditation providers that are also recognized as deeming authorities by CMS?
Yes. CIHQ will recognize accreditation by any other non-acute care hospital provider who has been recognized as having deeming authority by CMS. For example, if your hospital has a laboratory accredited by a deemed authority, CIHQ will accept that accreditation and not survey that department.
How frequently will CIHQ conduct accreditation surveys?
Full accreditation surveys are conducted every three years.
How long are the surveys?
The length of full surveys will depend on the size and complexity of your hospital. An average size hospital will likely have a 2-4 day survey with a team of 2-4 surveyors – including a facilities specialist.
Who conducts the surveys?
Surveys are conducted by full-time clinicians with years of experience in the hospital setting. Surveyors undergo a rigorous training program and are nationally certified in this field.
We have disease specific certifications by our current accreditation provider. Does CIHQ offer disease specific certification?
Yes, CIHQ currently offers Disease Specific Certification (DSC) for the following:
- Acute Stroke Ready Hospital
- Primary Stroke Center
- Heart Failure
- Joint Replacement Surgery
- Primary Heart Attack Center
In addition, CIHQ offers “Center of Excellence” designations in the following areas:
- Long-Term Acute Care
- Rehabilitation Services
- Rehabilitation Services - Stroke Care
- Nursing Services
- Respiratory Services
- Environmental Health & Safety
- Palliative Care
- Emergency Services
Our current accreditation provider requires us to conduct an internal self-assessment or undergo a survey to their standards every year. Is this required by CIHQ?
No. CIHQ does not require accredited facilities to perform or submit internal assessments of compliance to our standards.
Our current accreditation provider required us to become ISO certified. Is this required by CIHQ?
No. CIHQ does not require a hospital to seek additional certifications or mandate adoption of a particular performance measurement or improvement program.
Our current accreditation provider requires us to submit core measure data to them. Does CIHQ require this?
No. CIHQ does not require submission of core measure or other quality measurement data. Accredited hospitals would be required to honor their CMS reporting requirements but would not be required to also report data to CIHQ.
Our current accreditation provider often requires us to submit evidence of a root cause analysis for sentinel events. Does CIHQ require this?
No. CIHQ does not require accredited hospitals to report sentinel events or submit root cause analyses of those events.
What resources will CIHQ make available to help hospitals with accreditation?
CIHQ provides the following resources at no additional charge to accredited organizations:
- Unlimited site-wide access to our standards and survey procedures in both electronic and PDF format
- Monthly webinars on how our standards are surveyed with an opportunity for accredited hospitals to get their questions answered
- Template policies, forms, staff training aides, and other documentation tools to assist in your compliance efforts
- Discounted rates on attendance (you pay only travel expenses) at our annual Accreditation & Regulatory Summit
- Unlimited access to a web-based reference and staff training libraries
- Alerts to changes in standards and CMS regulations as well as unlimited access for standards interpretation.
- And much more...
Can CIHQ provide consultants to help us prepare for your survey?
CMS forbids accrediting organizations from providing consulting services. CIHQ surveyors cannot act as consultants or assist a hospital in this regard. However, our consulting division called Accreditation Resource Services (ARS) can assist you and provide consulting service for our accreditation program.
How does a hospital apply to become accredited?
There is a simple on-line application process.
How much will CIHQ charge for being accredited?
The cost will depend on the size and complexity of the organization. There is a flat fee that will be billed annually. We do guarantee that our pricing will either meet or be lower than other accreditors. If you have received a lower cost from another accreditor, please include any increase in fees the year of the survey and send it to us. We will meet or beat it.
We sustained a “condition-level” deficiency from our current accreditation provider during a recent survey. This required a follow-up survey, and we incurred an additional survey fee. Does CIHQ do this?
CMS requires a deeming authority to perform a follow-up survey within 45 days whenever a condition level deficiency is cited. However, you will not be charged an additional survey fee should this occur. You would only pay for the surveyors travel expenses.
We had a patient file a complaint with our current accreditation provider. This resulted in a complaint survey, and we incurred an additional survey fee. Does CIHQ do this?
CMS requires a deeming authority to investigate complaints. If this requires an on-site visit, you will not be charged an additional survey fee (up to two in a 12-month period). You would only pay for the surveyor’s travel expenses.
We would like to have someone from CIHQ contact us to discuss becoming accredited. How do we do this?
Please call or email:
Traci Curtis
Chief Operating Officer CIHQ
866-324-5080, Option 2
tcurtis@CIHQ.org
Traci Curtis
Chief Operating Officer CIHQ
866-324-5080, Option 2
tcurtis@CIHQ.org
Updated March 2023