ACHC 2025 Annual Report.
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTER
2025 annual report Conversations That Count
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2025 ANNUAL REPORT
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTERS
BOARD OF COMMISSIONERS
At the time of ACHC’s last year-in-review publication, building was top-of-mind as the expansion of our Cary, North Carolina headquarters was underway. Today, I’m reminded that my focus was both literal and figurative. Symbolically, building was a way to show that the careful nurture of relationships—growing connections that bridge disciplines and perspectives— expands ideas and yields richer results than a closed “members only” approach. With healthcare associations focused on advocacy, with organizations developing products that support our clients, and with individual healthcare provider and supplier entities, ACHC has consistently engaged in conversations designed to build something better.
Brock Slabach, MPH, FACHE chair Chief Operating Officer, National Rural Health Association Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN vice chair Owner and CEO, MSMP Anesthesia Services, LLC Mark S. DeFrancesco, MD, MBA, FACOG secretary Women’s Health Connecticut/Physicians for Women’s Health (retired)
Leonard S. Holman, Jr, RPh treasurer Healthcare Executive and Consultant
John Barrett, BSEE, MBA officer-at-large Senior Consultant, Quality Systems Engineering
Gregory Bentley, Esq. Principal, The Bentley Washington Law Firm
Richard A. Feifer, MD, MPH, FACP Chief Medical Officer, Innovage
In each case, we imagine, we discuss, we plan, we discuss, we execute, we discuss, we test, we discuss, and we adjust. To use a favorite phrase: It’s a nerdy process. But our enthusiasm, our passion, makes each collaboration fresh as we welcome participants with specific knowledge to share. And once again—in ACHC’s 40th year—we’ve proven that embracing the expertise of a wide range of stakeholders keeps us at the cutting-edge of what is possible in health care accreditation. Today, even as ACHC teams are settling into their spectacular new spaces, the outward focus on our constituents continues. Building and maintaining relationships with federal and state regulatory bodies and with provider and supplier organizations of all sizes affords ACHC a panoramic view of health care that spans trending topics at the macro-level while offering sightlines into the daily challenges facing organizations we serve. Sitting at the junction of regulatory mandates and individual implementation gives ACHC a unique perspective that has driven our progress for 40 years. We monitor the pulse of the industry to predict where those recurring, “hot topic” conversations will lead. Then we work—collaboratively, thoughtfully, passionately—to translate those insights into real value for our clients and partners. Some call us the Accreditation Nerds. Like many working in the healthcare space, ACHC leads with head and with heart. Our goal is to smooth the path forward for providers by supporting excellence
Jennifer Burch, PharmD, RPH, CDCES, FNCAP, FAPC Owner, Central Pharmacy, Central Compounding Centers José Domingos President and CEO, Accreditation Commission for Health Care
Denise Leard, Esq. Attorney, Brown & Fortunato
Marshelle Thobaben, RN, MS, PHN, APNP, FNP Professor Emerita, California State Polytechnic University, Humboldt
LEADERSHIP TEAM
José Domingos President and CEO
Matt Hughes Vice President, Community Care Services
in patient care and sustainability in business operations with relevant, timely education and meaningful standards. Our commitment is what has made ACHC the smart, modern choice for accreditation. For 40 years and counting.
Patrick Horine, MHHA Vice President, Acute Care Services
Jonathan Kennedy, CPA, MBA Vice President, Finance and Corporate Services
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2025 ANNUAL REPORT
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTERS
COMMUNITY CARE DIVISION
13 Accreditation Programs
12 Distinction Programs
HISTORY AND GROWTH ACHC’s story begins in 1986, when a small group of home care leaders and providers noticed a need and decided to embrace a new endeavor, head-on. At the grassroots level, they launched a project to create an accreditation option that was sensitive to the needs of small, home-based-care businesses in North Carolina. Their mission: to ensure a voice for providers.
age-friendly care
rare disease and orphan drugs
assisted living
behavioral health
behavioral health
In 2020, these organizations joined in the first merger of two accrediting organizations approved by the Centers for Medicare and Medicaid Services (CMS). Today, ACHC is an internationally recognized accrediting body with customers across the United States and beyond. We deliver consistent, best-in-class accreditation for organizations dedicated to delivering high- quality patient care. Driven by a customer-focused mission, in 2025 ACHC included 39 programs across two divisions. As an enterprise, we strive to demonstrate our commitment to continuous improvement through education—relevant, timely, ongoing.
hazardous drug handling
clinical respiratory management
dentistry
outcomes
dmepos
custom mobility
palliative care
home care
ig therapy
rare disease and orphan drugs
home health
infectious disease specific to hiv
telehealth
home infusion therapy
Decades before, in Chicago, an accreditation program was launched to validate quality in hospitals. Each of these programs independently focused on a customer-first, education-based approach to building quality in healthcare organizations. And each expanded into additional settings and services as new needs were identified.
hospice
3 Certification Programs
palliative care
healthcare staffing services
pcab compounding
long-term care dialysis
pharmacy
telehealth
renal dialysis
sleep
mission
ACUTE CARE DIVISION
We aim to deliver the best possible experience and to partner with organizations and healthcare professionals that seek accreditation and related services.
7 Accreditation Programs
4 Certification Programs
joint replacement
acute care hospital
clinical laboratory
vision
lithotripsy
ambulatory care
critical access hospital
stroke
We will be the preferred choice for accreditation services that benefit and inspire the providers, employees, and communities we serve.
ambulatory surgery center
in-home hospital care
wound care
office-based surgery
of our customers would recommend ACHC
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2025 ANNUAL REPORT
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTER
workplace violence Building a “culture of safety” is a laudable goal, but it’s not easy to achieve when statistics offer clear evidence that workplace violence is escalating in healthcare settings. Growing numbers of healthcare workers have faced threats, aggressive behavior, and actual harm. And the psychological and emotional stress, especially for those who have experienced actual violence, serves to worsen staffing shortages (see above). One challenge exacerbates another. How did ACHC support organizations to address this challenge in 2025? ACHC Hospital Accreditation includes a standard addressing workplace violence and this year the expected risk assessment and corresponding mitigation measures were further addressed through focused education. ACHCU offered “Insights on Workplace Violence” – a three-session Master Class series (now available on-demand) presenting
Physicians and metal health workers are also facing critical shortages. How did ACHC support organizations to address this challenge in 2025? Standards across all programs provide clear guidance for staff onboarding and ongoing training to ensure that competencies are maintained without sacrificing continuity of services. ACHC Healthcare Staffing Services
INDUSTRY ENGAGEMENT
Sitting at the junction of regulatory mandates and individual implementation gives ACHC a unique perspective that has driven our progress for 40 years. We monitor the pulse of the industry to predict where those recurring, “hot topic” conversations will lead. — José Domingos, President and CEO
Certification continues to offer validation that staffing agencies
understand and achieve compliance which, in turn, supports confidence for organizations seeking to maintain quality amid turnover with interim staffing solutions. Individual certifications like Compliance and Quality Certification for home health and hospice offered by ACHCU are designed to build skills and deepen engagement for nursing staff. Several ACHC experts (Rommie Johnson, Program Director, ASC and Office-Based Surgery Accreditation, for example) regularly post articles focused on accomplishing tasks with low-tech, simple processes that support quality in organizations where staff perform multiple roles. Free webinars led by internal and external experts, and other educational opportunities specific to ACHC program areas support knowledge sharing among nursing and administrative professionals with practical tips for managing common challenges.
cost pressure The “One Big Beautiful Bill Act” signed in 2025 is the largest rollback of federal support for health care in American history, according to the Center for Medicare Advocacy. Provisions of the Act impact health care for patients and for provider/supplier organizations. Narrowed eligibility for Medicare, Medicaid, and ACA Marketplace subsidies will limit access to coverage, driving up costs for consumers. Diminished federal funding and increases in unreimbursed care will reduce revenue for hospitals. Caps on federal loans for medical students and reclassification of nursing disincentivize these career paths. How did ACHC support organizations
Building organizational efficiency is another way to address financial pressure. Throughout 2025, ACHC experts applied their experience and problem-solving mindset to imagine and develop resources that allow organizations to do less with less when that is the reality they face. Richard Parker, Associate Program Director, Life Safety and Physical Environment, is a frequent advocate for the use of risk assessments before adding equipment. His ACHC blog post Risk Assessments Drive Emergency Showers, Eyewash Stations , serves as an example of the process he espouses: Assess risk, verify performance over presence, and use annual risk assessment reviews as a strategic tool. The concept is to create operational efficiencies that keep your staff working “at the top of their license” rather than spending time on tasks that don’t add value for the organization. staffing shortages An aging U.S. population is creating demand for long-term and home-based care at the same time that nurses are reaching retirement age in significant numbers. Burnout in the post- pandemic environment is an additional factor contributing to nursing shortages and the pipeline of new professionals is at risk as the Department of Education proposes federal loan limits on nursing education.
strategies to evaluate a hospital’s organizational and environmental risks, develop proactive mitigation approaches, and address education and training needs for staff and volunteers.
to address this challenge in 2025? Budget management is perhaps the most obvious means of addressing financial pressure. But cost cutting does not represent true
Some organizations are initially attracted to ACHC because our deemed programs stick close to federal regulations without adding a lot of additional requirements. Often, these same organizations end up our strongest advocates because of the scope of knowledge we bring using those standards as our framework. When your staff really understands compliance, it represents measurable value, especially when margins are thin. — Patrick Horine, Vice President, Acute Care Services
savings, if it increases risk. ACHC believes that accreditation builds better, safer, more reliable, more sustainable healthcare organizations. We also believe that cost should not be the barrier to an organization seeking that goal. For organizations that may be financially stressed, we have developed a range of payment plans and opportunities to bundle services while you manage risk by maintaining the quality that is supported by ACHC Accreditation.
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2025 ANNUAL REPORT
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTERS
associations These organizations offer valuable resources and advance legislative agendas for the benefit of their constituents.
Alliance for Pharmacy Compounding American Association for Homecare American Association of Sleep Technologists American College of Apothecaries American Mobile & Teledentistry Alliance Arizona Association for Home Care Arizona Hospice & Palliative Care Organization Association for Home & Hospice Care of North Carolina Atlantic Coast Medical Equipment Services Association California Ambulatory Surgery Association California Association for Health Services at Home California Hospice and Palliative Care Association Community Oncology Pharmacy Association Connecticut Association for Healthcare at Home Florida Alliance for Health Care Services Health System Owned Specialty Pharmacy Alliance Home Care Alliance of Massachusetts, Inc. Home Care & Hospice Association of New Jersey
Home Care Association of New York State Illinois Homecare & Hospice Council Immunoglobulin National Society (IgNS) Indiana Association for Home & Hospice Care, Inc. Kansas Home Care & Hospice Association Kentucky Home Care Association Louisiana-Mississippi Hospice & Palliative Care Michigan HomeCare & Hospice Association National Association of Specialty Pharmacy National Rural Health Association Ohio Council for Home Care & Hospice Pennsylvania Homecare Association Rhode Island Partnership for Home Care Tennessee Association for Home Care Texas Association for Home Care & Hospice Texas-New Mexico Hospice & Palliative Care Organization Texas Medical Equipment Providers Association The US Oncology Network Virginia Association for Home Care and Hospice
STRATEGIC PARTNERS
We have established a reputation as professional but approachable; an innovative leader in the accreditation space. That’s why so many organizations seek to partner with ACHC. — Matt Hughes, Vice President, Community Care Services
Home Care Association of America Home Care Association of Florida
vendors These organizations offer products that support compliance with ACHC accreditation standards, data management, and regulatory requirements.
Accredited Home Healthcare Directory Accurate Accreditation AndHealth Axxess BetterRX
Careficient CarepathRx Specialty Pharmacy & Infusion Solutions Cencora Clearway Health corecubed Corridor CPS Fairview Pharmacy Solutions
Fairway Health and Wellness Health Recovery Solutions Home Options Network (Vantive) HospiceMatch, Inc. HOTB Software Solutions InPro Insurance Group
Managed Health Care Associates, Inc. MedEdge Solutions MedForms NGA Healthcare NikoHealth Omnicell Partner Plus Media PowerDMS, Inc.
Precision Medical Billing ProTek QAPIplus QPI Healthcare Services, LLC Qualis RLDatix SafeQual Shields Health Solutions SimiTree
Soleran SomniTech STACK Storey Marketing Surglogs TempAid Cold Chain Packaging
Cardinal Health Pharmacy Services Cardinal Health VitalSource GPO Care Pharmacies Cooperative, Inc.
Kantime Lumicera McKesson
Visante VytlOne Worldview
franchisors
AHI Group Always Best Care
Boost Home Healthcare ComForCare
First Day Homecare Preferred Care at Home
Vital Care, Inc
These organizations provide onboarding and continuing education about the benefits of accreditation to their franchisees.
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2025 ANNUAL REPORT
CONVERSATIONS THAT MATTER
CONTINUOUS IMPROVEMENT
program growth ACHC welcomed new program leaders in 2025.
Caroline Girardeau, PharmD, MBA, PMP, BCPS was appointed Director of the Pharmacy and PCAB Programs. Caroline brings expertise in life sciences, data analytics, drug development and pharmacy practice to her role.
As Accreditation Nerds, we imagine, we discuss, we plan, we discuss, we execute, we discuss, we test, we discuss, and we adjust. — José Domingos, President and CEO
Deborah Panza, RRT, RPSGT joined ACHC as Associate Program Director for the DMEPOS, Mobile Dentistry, and Sleep Programs. Deborah’s knowledge of regulatory compliance founded on decades of clinical leadership in respiratory therapy, sleep and DMEPOS uniquely positions her to support organizations that seek to elevate the care they deliver to their patient populations.
revamped website In 2025, ACHC unveiled a redesigned website designed to provide a meaningful introduction for organizations new to accreditation and for those seeking to transition to a smart, modern approach. The site also serves existing customers with highlighted resources and updated content.
new building Our stunning, expanded headquarters opened in 2025.
The achc.org homepage celebrates our staff of Accreditation Nerds and makes our most recent articles, videos, webinars, and events easily accessible. Each setting we serve has dedicated resources so you can learn more about the programs most relevant to your needs.
navigator
Continuous improvement is the name of the game for ACHC Accreditation Nerds. To enhance the accreditation experience for our customers, ACHC Nerds worked throughout 2025 on a new customer platform. Navigator began its phased launch in 2025. It provides a simpler, faster, clearer way to see manage your organization’s accreditation cycle.
Do you suffer from CAF? For organizations accredited by others, Navigator is the cure* for Chronic Accreditation Frustration (CAF) that afflicts organizations accredited by others. * ACHC Navigator is not for everyone. Do not use Navigator if you are not interested in a smoother accreditation process or if you enjoy a complicated, confusing and frustrating accreditation process. Talk to ACHC if you have a history of struggling while using other accreditation platforms, as this may increase your risk of Navigator side effects. If at any time while using Navigator, you experience feelings of elation , smiling , a release of muscle tension , joyful exclamations , clapping of hands or general positive feelings , congratulations…you are experiencing the benefits of Navigator.
With a cleanroom facility as part of our education space, we can now offer focused onsite training for compounding pharmacies at our facility.
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2025 ANNUAL REPORT
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTER
EXPERTISE IN ACTION
Cyndi Newman, MSHL, BSN, RN Senior Clinical Review Specialist Linking ASC Privileging to Peer Review, OR Today
Our teams shine when they show that accreditation isn’t separate from the lived experience of healthcare organizations. Instead, the knowledge it imparts adds value when managing all kinds of challenges and change. — Matt Hughes, Vice President, Community Care Services
Deborah Panza, BS, RRT, RPSCT Associate Program Director Sleep Survey Experts Reveal the 6 Most Common Accreditation Deficiencies, Surfing the Sleep World with Michael D (podcast) Richard Parker, MBA, CHFM Associate Director, Life Safety & Physical Environment Four Key Components to Surgical Fire Prevention, Healthcare Construction & Operations News Beyond Routine: Specialized Fire Drills in ORs, OR Today Putting an Emphasis on Surgical Fire Prevention, P atient Safety and Quality Healthcare (podcast) Life Safety: What Admins Need to Know, HST Pathways, T his Week in Surgery Centers (podcast) Mastering the Art of Survey Preparation: A Guide for Facility Managers, Soleran.com (guest blog)
Amy Antonacci, MSN, RN Senior Standards Interpretation Specialist Connecting Regulatory Requirements to Care, OR Today
Tricia Dixon-Thomas, MSN, RN Senior Clinical Review Specialist Managing Contracted Services, OR Today
Deanna Scatena, RN Hospital Program Director Elevating Standards in Surgery through Accreditation, OR Today
Kelly Dragon, MSN, RN Clinical Review Specialist Are You Trading Efficiency for Safety in your ASC?, Patient Safety and Quality Healthcare Rachel Graham, CRT, RCP, RPSGT Corporate Surveyor/Virtual Coordinator Sleep Survey Experts Reveal the 6 Most Common Accreditation Deficiencies, Surfing the Sleep World with Michael D (podcast)
Karen Spano, RPh, HDDP ACHCU Pharmacy Educator
Preparing for Specialty Pharmacy Reaccreditation with ACHC, Clearwayhealth.com (guest blog) PCAB Accreditation as a Safety Net: GLP-1 Demand and Spotlight on Compounding Standards, Pharmacy Times
Julie Vandenbark, MLS, BSN, RN Senior Standards Interpretation Specialist Patient Safety and the Post-Anesthesia Assessment, OR Today Keep it Safe: Using IUSS Effectively, OR Today
Rommie Johnson, MPH, PMP Program Director, Ambulatory Surgery Centers & Office-Based Surgery Credentialing and Privileging: A Guide to Compliance, OR Today
Madelyn Jo May, RN, CNS, DNP Surveyor Rethinking the Surgical Time Out, OR Today
Good conversations can happen anywhere.
55 CONFERENCES & EXHIBITS
55 FREE WEBINARS
2,811 Coffee Chat Participants
Lisa Meadows, MSW Senior Manager, Survey Operations Doing More with Less: Compliance, Education, and Support from ACHC, Home Health Revealed (podcast)
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2025 ANNUAL REPORT
CONVERSATIONS THAT MATTER
IMPROVEMENT OPPORTUNITIES
behavioral health
Our report of the most frequently-cited standards can be reviewed in the program- specific Quality Review editions of Surveyor, Vol. 2025, No. 2 .
0%
100%
The charts that follow illustrate the weighted distribution of deficiency findings, by program. This high-level overview indicates where focused improvement efforts can have positive impact for an organization across a group of functionally-related standards.
7%
15%
4%
21%
12%
9%
Organization & Administration Provision of Care and Record Management represents the biggest improvement opportunity for behavioral health organizations. The focus of these standards is how treatment and interventions are planned, delivered, and evaluated. At each step, complete and accurate documentation authenticates service delivery and supports continuity of client care. Program/ Service Operations Fiscal Management Human Resource Management Provision of Care & Record Management Quality Outcomes/ Performance Improvement Risk Management: Infection & Safety Control
community care programs The categories identified in the legend reflect the sections into which ACHC standards are organized. The sections are defined as follows:
1. Organization and Administration ■ Leadership structure including governing body, advisory committees, management, and employee responsibilities, conflicts of interest, and reporting relationships ■ Business licensure, program goals, and regulatory compliance 2. Program/Service Operations ■ Patient and organizational rights and responsibilities, complaints, incidents, management of Protected Health Information, cultural diversity, and compliance with fraud and abuse laws 3. Fiscal Management ■ Annual budgeting process, business practices, accounting procedures, and financial processes 4. Human Resource Management ■ Requirements for personnel records, including training and competency assessments
5. Provision of Care and Record Management ■ Documentation and requirements for the
dmepos
service recipient/client/patient record ■ Operational aspects of care/services provided
0%
100%
3%
8%
19%
22%
13%
14%
21%
6. Quality Outcomes/Performance Improvement ■ Plan and implementation of a
Performance Improvement (PI) program ■ Program responsibilities, data collection, analysis, corrective measures developed from the data, and outcomes achieved
Organization & Administration DMEPOS opportunities for improvement are distributed across categories with HR Management and Risk Management: Infection and Safety Control showing slightly higher percentages of aggregate standard deficiencies. Fiscal Management Human Resource Management Provision of Care & Record Management Program/ Service Operations
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
7. Risk Management: Infection and Safety Control
■ Surveillance, identification, prevention, control, and investigation of infections and safety risks ■ Fire safety, hazardous material handling, and disaster and crisis preparation
Section 3: Fiscal Management
Section 4: Human Resource Management
Section 2: Program/Service Operations
Section 1: Organization & Administration
Section 5: Provision of Care and Record Management
Section 6: Quality Outcomes/ Performance Improvement
Section 7: Risk Management: Infection and Safety Control
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CONVERSATIONS THAT MATTER
home care
home infusion therapy
0%
100%
0%
100%
6%
18%
22%
37%
8% 7%
7% 18%
6% 10%
41%
9% 9%
2%
Organization & Administration The distribution of deficiencies on Home Care surveys in 2025 is very consistent with last year’s findings. The preponderance of issues fall into Provision of Care and Record Management. Training on documentation practices is a recommended improvement action. Fiscal Management
Organization & Administration While the most frequent individual standard deficiencies came from Provision of Care and Records Management, 2025 saw an increase in the area of Program/Service Operations. These standards generally focus on required policies. Improvement opportunities exist in policy implementation. Fiscal Management
Program/ Service Operations
Human Resource Management
Provision of Care & Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
Program/ Service Operations
Human Resource Management
Provision of Care & Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
hospice
home health
0%
100%
0%
100%
7% 14%
23%
48%
5%
3%
4% 7%
10% 12%
9%
56%
2%
Organization & Administration Hospice providers have the greatest opportunities for improvement in the area of Provision of Care and Records Management. Last year, this section represented more than half the overall deficiencies; this year’s result showed a greater than 12% improvement. Fiscal Management
Organization & Administration While Home Health still has opportunity in Provision of Care and Record Management, the relative percentage (56%) improved from 2024 (62%) indicating that agencies are working issues, especially with regard to documentation practices. Fiscal Management
Program/ Service Operations
Human Resource Management
Provision of Care & Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
Program/ Service Operations
Human Resource Management
Provision of Care & Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
Section 3: Fiscal Management
Section 4: Human Resource Management
Section 5: Provision of Care and Record Management
Section 6: Quality Outcomes/ Performance Improvement
Section 7: Risk Management: Infection and Safety Control
Section 2: Program/Service Operations
Section 1: Organization & Administration
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CONVERSATIONS THAT MATTER
pharmacy
sleep
0%
100%
0%
100%
1%
5% 13%
3% 13%
15%
22%
10%
37%
28%
15%
26%
12%
1%
Organization & Administration Pharmacy results are very consistent year over year with only a minor uptick in 2025 in the number of findings related to Risk Management: Infection and Safety Control. This represents deficiencies identified across 60 individual standards, many pertaining to requirements for written policies and procedures. Fiscal Management
For sleep-accredited settings, just over half the total deficiencies are from standards related to Human Resource Management and Quality Outcomes/Performance Improvement.
Program/ Service Operations
Human Resource Management
Provision of Care & Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
Organization & Administration
Program/ Service Operations
Fiscal Management
Human Resource Management
Provision of Care & Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
compounding pharmacy (pcab)
renal dialysis
0%
100%
0%
100%
15%
41%
20%
10% 6% 1%
5%
8%
5% 8% 9%
28%
43%
PCAB Standards vary from the grouping used by other ACHC programs. Opportunities for improvement in compounding compliance are greatest in the area of risk management.
Again in 2025, Risk Management: Infection and Safety Control represent the greatest opportunity for improvement for providers of dialysis.
Organization & Administration
Program/ Service Operations
Fiscal Management
Human Resource Management
Provision of Care & Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
Program/Service Operations Section 2
Organization & Administration Section 1
Personnel Training and Competency Section 3
Section 3: Fiscal Management
Section 4: Human Resource Management
Section 2: Program/Service Operations
Section 1: Organization & Administration
Patient Communications Section 4
Quality Outcomes/ Performance Impro vement Section 5
Provision of Care and Record Management Section 6
Hazardous Drug Handling
Section 5: Provision of Care and Record Management
Section 6: Quality Outcomes/ Performance Improvement
Section 7: Risk Management: Infection and Safety Control
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CONVERSATIONS THAT MATTER
ambulatory surgery centers
acute care programs For ACHC acute care programs, standards are organized in chapters that tie to specific departments or functions. Refer to the legend associated with each chart to identify which chapters are included in the distribution of deficiencies. A dominant percentage indicates that those chapters may offer the greatest opportunity for overall organizational improvement in this particular setting.
0%
100%
29%
18%
9%
19%
25%
Administrative Deficiencies in ambulatory surgery centers were fairly evenly distributed across categories with slightly more deficiencies in standards addressing Administrative and Quality and Risk Management topics. Direct Patient Care Ancillary Patient Care Services Facilities Management
Quality & Risk Management
Direct Patient Care Chapters 9, 10, 11
Ancillary Patient Care Services Chapters 12, 13, 14
Administrative Chapters 1, 2, 3, 8
Facilities Management Chapters 7, 15, 16
Quality & Risk Management Chapters 4, 5, 6
acute care hospitals
critical access hospitals
0%
100%
0%
100%
11%
24%
3%
47%
16%
9% 13%
11%
42%
25%
Administrative In Critical Access Hospitals, the greatest opportunity for improvement is in Facilities Management where deficiencies across the relevant chapters remained at the same level as 2024 findings. Direct Patient Care standards represent the next best opportunity with, not surprisingly, most deficiencies coming from chapter 6 | Provision of Services with its many subsections. Direct Patient Care Ancillary Patient Care Services Facilities Management Quality & Risk Management
Administrative Facilities Management represented the largest opportunity for improvement in hospitals surveyed in 2025, with most of the deficiencies coming from the Life Safety chapter. Direct Patient Care Ancillary Patient Care Services Facilities Management
Quality & Risk Management
Direct Patient Care Chapters 10, 16, 17, 18, 20, 26, 27, 30, 31, 33, 34
Ancillary Patient Care Services Chapters 14, 19, 21, 22, 23, 24, 25, 32
Administrative Chapters 1, 2, 3, 4, 6, 8
Direct Patient Care Chapters 2, 6, 8, 12, 13
Ancillary Patient Care Services Chapters 10, 11, 19
Administrative Chapters 1, 4, 5, 7
Facilities Management Chapters 9, 11, 13
Quality & Risk Management Chapters 7, 12, 15
Facilities Management Chapters 3, 14, 17
Quality & Risk Management Chapters 9, 16, 18
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CONVERSATIONS THAT MATTER
office-based surgery
0%
100%
of our customers regard their experience with ACHC as positive
11%
36%
10% 7%
36%
3 NEW CERTIFICATIONS IN 2025 ACCREDITATION PROGRAMS 20
Administrative In 2025, standards related to Administration and Risk Management offered the greatest opportunities for improvement for OBS practices. Because these tend to be smaller organizations, management of administrative and risk-related activities may be lacking the foundational policies and procedures found in larger organizations or the training associated with them may not be adequately formalized to meet expectations. Direct Patient Care Ancillary Patient Care Services Facilities Management Quality & Risk Management
5 MASTER CLASS SERIES NEW
WEBINAR REGISTRANTS 14,150
Direct Patient Care Chapters 9, 10, 11
Ancillary Patient Care Services Chapters 12, 13, 14
Administrative Chapters 1, 2, 3, 8
Facilities Management Chapters 7, 15, 16
Quality & Risk Management Chapters 4, 5, 6
NEWSLETTER SUBSCRIBERS
6 CERTIFICATIONS FOR INDIVIDUALS
4% INCREASE in laboratories using IQCP E-Optimizer
clinical laboratory
0%
100%
9%
13%
13%
7%
15%
35%
3%5%
HealthTrainU Tests Taken 45,502
125,728 did you know? recipients
General Laboratory Compliance with standards for Analytic Systems remains the biggest challenge for laboratories and presents the biggest opportunity for improvement. Laboratory Personnel Proficiency Testing General Systems Analytic Systems Pathology
Provider Performed Microscopy &
Specialty- Subspecialty Specific
Immuno- hematology & Transfusion Services
Waived Testing
serving for home care, home health, and hospice agencies CERTIFICATIONS FOR PRODUCTS & PROGRAMS 11
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2025 ANNUAL REPORT
achc.org
achcu.com
labuniversity.org
healthtrainu.com
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