By following these three steps, you can achieve accreditation readiness by incorporating accreditation standards into your daily business practices.
By following these three steps, you can achieve accreditation readiness by incorporating accreditation standards into your daily business practices.
by Cora Colvin

For durable medical equipment (DME) suppliers, the CMS accreditation process can seem like a hassle. It’s another box to check in the already arduous process that’s required in order to bill Medicare.

It’s true that some effort is required to achieve CMS accreditation. Yet with the right approach, the process can not only be streamlined, it can also provide broader value by offering a useful tool for monitoring key components of your business—and improving your operations in the bargain.

Accreditation standards provide a strong foundation for good service, quality care and compliance. For example, CMS-approved accrediting organizations provide very detailed standards to their clients—including guidance as to what an inspector will review during an audit. You can use this guidance as the basis for an internal tool that supports the monitoring of key aspects of your organization that impact quality and compliance.

A critical first step to building that sort of tool is to bring your operations and compliance leaders together to develop accreditation-readiness protocols and the foundational standard operating procedures that set the tone for accreditation compliance throughout the year. When components of your accreditation standards are incorporated into the current key performance indicators (KPIs) being monitored by leadership, you will save your organization the stress of the last-minute push to be survey-ready, while also adding valuable operational protocols that are focused both on compliance and also
overall quality.

By following these three steps, you can achieve accreditation readiness by incorporating accreditation standards into your daily business practices:

  1. Incorporate the performance improvement standards from accrediting bodies as part of your operational foundation.
  2. Measure your progress by using the standards to guide your internal monitoring and auditing.
  3. Craft your annual written report based on the results of that internal monitoring.

Your accrediting body likely requires your organization to identify a performance improvement program that includes organizational tracking of KPIs, one being the quality of service and/or care provided by your organization. KPIs are expected to be measured, analyzed and communicated across the organization from the top (that is, the governing body or owner) down to branch or warehouse staff.

We recommend taking the performance improvement standards and aligning them with the current management KPIs that are being measured, and communicating this throughout the organization at least once
a quarter.

For example, bring the performance improvement standards to your strategy planning meeting for the upcoming year and take time to identify personnel who will be responsible for ensuring the annual goals are structured in alignment with the guidance provided by your accrediting body. By doing this, your annual goals and future management meetings will have important accreditation components baked right in.

Good Habits for Compliance Culture

  • Ensure the goals and performance improvement indicators being monitored are communicated to appropriate staff.
  • Set a regular cadence for data reporting and review.
  • Include the data and analysis in your already-established quarterly leadership meetings. If your organization does not currently have quarterly leadership meetings to review performance, it is critical to establish them.

While each accrediting body has its own unique approach to credentialing and auditing its clients, they have also developed largely consistent standards that can be used for internal monitoring and auditing within your organization. As you work to adopt those standards, we strongly recommend involving your compliance department.

First, work with your compliance department or staff member to identify the high-risk processes or areas that have been identified as deficient during previous surveys or audits. Then, create an internal monitoring and auditing cadence that sufficiently addresses the risk. It is also best practice for the operations teams to self-monitor and report their findings to the compliance department monthly. The people responsible for compliance should then conduct quarterly audits based both on risk and the reported outcomes from the monitoring being conducted by the operations staff.

By incorporating these monitoring and auditing practices into your current operations procedures, you will reduce the amount of effort required when you prepare for reaccreditation.

Your accrediting body likely requires an annual written report that is comprehensive and describes the performance improvement activities, findings and corrective actions that relate to the care and service provided by your organization over the past year. By implementing the performance improvement, auditing and monitoring steps above into an ongoing process, your organization will have already collected important data that is required for your annual written report. Simply summarize these quarterly reports into a single report and a significant portion of your annual report is complete.

It can be just that simple!

Cora Colvin, MBA, CHC, is a regulatory and compliance professional with more than 13 years of experience in the health care space. She recently served as the chief ethics and compliance officer and chief privacy officer for a large medical device company. In addition to her health care compliance background, Colvin has extensive experience working with state regulatory agencies and licensing compliance for pharmacy, the Drug Enforcement Agency, the Environmental Protection Agency, food, liquor, drug manufacturing, distribution and durable medical equipment. Visit