Continuing Accreditation

Health Information Management Continuing Accreditation

Accredited programs will undergo the annual reporting and monitoring process through the Annual Program Assessment Report (APAR). Additionally under the Standard for Administrative Requirements for Maintaining Accreditation the program must participate in a CAHIIM Comprehensive Accreditation Review with a site visit as determined by CAHIIM. Programs may also be assigned a Focus Review if APAR outcomes consistently trend below an unacceptable level or there is credible evidence of noncompliance within the Standards.

CAS (CAHIIM Accreditation System) is the online system for Comprehensive Accreditation Review for Continuing Accreditation applicants. Upon notification of the review process the program is immediately provided access to the Self-Assessment stage and must complete all questions and Items of Evidence by the provided Due Date.

Timeline

4.3.4. HIM continuing-accreditation-timeline

Self-Assessment Stage: Program Submits information based on the Standards

Required Forms for completion and file uploads in this stage:

1. Program Evaluation Plan (required template for Standard #3. Program Effectiveness Measures)
2. Budget Template (required template for Standard #16. Financial Support)
3. Synopsis of Curriculum (required template for Standard #18. Curriculum)
4. Curriculum Requirements (required for Standard #18. Curriculum) Complete the applicable template mapping program courses to required curriculum content.
5. Learning Management System (required template for Standard #18. Curriculum)

Online Content Delivery

Academic technologies, software applications and simulations, and online or web-enhanced courses, have a significant role in the learning environment. To fairly evaluate online content the program must provide CAHIIM with full access to all online course content and relevant education applications used to deliver this content.

Helpful Tips:

1. Remove text formatting using a Text editor or Notepad software.
2. PDF documents should be uploaded unless its a specific CAHIIM form.

CAHIIM Review

A formal staff review and assessment of the information submitted. An assessment will be provided within 90 days. A request for clarification or additional information may be requested and is reviewed by CAHIIM quality education staff in the order received.

Site Visit

The site visit of the program verifies the accuracy of documentation submitted by the program. The site visit team will meet with program officials to seek conformity with the CAHIIM Accreditation Standards. After the site visit is concluded the site visit team will complete a Site Visit Report stage in the CAHIIM Accreditation System (CAS).

Download the following documents for this stage:
1. Site Visit Checklist
2. Site Visit Itinerary Template

Program Response

A formal response to the site visit results is requested from the program director within 30 days.

Council and Board Review

An accreditation recommendation and accreditation decision is provided to the program at the next available meetings. Any program may be awarded a 6 month Progress Report to be submitted if there exists Standard deficiencies that remain that require time for implementation. This information will be required to be completed in the CAHIIM Accreditation System by the CAHIIM specified due date.

Progress Report Requirement

In order to maintain accreditation status the program must submit a progress report that satisfies the remaining Standard deficiencies that resulted from the review process.

The Board Report will reflect the current Not Met or Partial Met Standard deficiencies that require the institution’s attention and provides guidelines for resolution and evidence of implementation in order to achieve full compliance for the program.

Progress Report Deficiency Validation Tool template: This format must be used for completing partial met and not met curricula considerations for Standard 18.

Failure to submit this report by the due date may place the program on Administrative Probationary Accreditation. An unsatisfactory progress report or a Substantive Change in Program Director during the progress report process may result in a Focused Review and site visit of the program.

Information Regarding Access to and Retention of Documentation in the CAHIIM Accreditation System (CAS)

Programs need to print copies of each section of the self-assessment in the CAHIIM Accreditation System (CAS) while going through the continuing accreditation process. Access to CAS is terminated after the program receives a final accreditation decision and Standard deficiencies noted in the Progress Report, if applicable, have been resolved. Documents are not permanently accessible and may not be available on short notice. If a program needs copies of the self-assessment submissions, at least 30 days’ notice must be given to CAHIIM and fees will apply for reproduction and shipping of the documentation.

Situations that Adversely Affect the Application Process

Change in Program Director: A change in program director is prohibited during the application process and will lead to removal of Candidate Status and application rejected if the Self Assessment stage has already been submitted in the CAHIIM Accreditation System.

Accredited programs must notify CAHIIM within 30 days of a change in program director. The program
may identify the new Director as one of the following:

• Permanent Program Director: a candidate that does meet the qualifications of the position as
stated in the CAHIIM Accreditation Standards.

• Interim Program Director: a candidate that does meet the qualifications of the position as stated
in the CAHIIM Accreditation Standards, and a search process is in progress for a permanent
candidate.

• Acting Program Director: a candidate that does not meet the qualifications of the position as
stated in the CAHIIM Accreditation Standards, and a search process is in progress for a
permanent candidate.

Complete the form at this link including all steps for a Permanent, Interim or Acting Program Director.

Payment: An invoice will be sent for the $250 Substantive Change Fee after the approval of the Program
Director change form has been completed and a confirmation letter is provided.

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