There is a little nerd in us all! Take our quiz to find out if you are an Accreditation Nerd.
SURVEYOR Volume 2026 | No. 1
What kind of ACCREDITATION NERD are you? Pg. 13 Take the quiz to find out!
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Reflections from José Domingos
ACHC President and CEO
TABLE OF CONTENTS CEO MESSAGE 01
In 1986, the North Carolina Accreditation Commission for In-Home Aide Services was founded. Forty years later, that organization is an internationally known accreditor with programs that span much of the continuum of care. ACHC has achieved a lot in four decades and I attribute our success to four constants .
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DEVELOPING NERDS
22
02
ACUTE CARE SERVICES
LISTENING AS STRATEGY
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04
CHIPPING IN FOR CHARITY
COMMUNITY CARE SERVICES
1.
Quality Quality in healthcare is achieved at the intersection of safety, clinical effectiveness, efficiency, consistency, and patient- centeredness. ACHC Standards focus on these components. Our staff and surveyors have always been deeply committed to helping organizations maximize their individual capacity for measurable excellence. Innovation Innovation can be born of necessity or of curiosity – two very different sources. Both have served as an impetus for ACHC’s growth. When the COVID pandemic limited onsite surveys, ACHC developed the first virtual survey process approved by Medicare for certain programs. When hospital surveyors noted an increase in citations related to cleaning, sterilizing, and storing endoscopes, our team dug in
and wrote new standards with detailed guidance to clarify expectations and deficiencies significantly decreased. Accountability ACHC is the only ISO 9001-certified accreditor. That means we’re surveyed every year. If we expect accountability from our customers, we should expect it from ourselves. Without accountability, you drift. Being one degree off course doesn’t seem like much at first but over time, you miss the target entirely. That’s why continuous compliance matters. Caring I think healthcare calls you because you’re wired to care. You care about the details. You care about safety. You care about things others overlook. It’s the foundational impulse that also drives quality, innovation, and accountability.
BOARD OF COMMISSIONERS
3.
officers:
members:
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 José Domingos President and CEO, Accreditation Commission for Health Care Richard A. Feifer , MD, MPH, FACP Consultant, Advisor, and Board Member Denise Leard, Esq. Attorney, Brown & Fortunato Marshelle Thobaben, RN, MS, PHN, APNP, FNP Professor Emerita, California State Polytechnic University, Humboldt
2.
4.
At ACHC, we’ve anchored our culture in the idea that a “nerd” is someone who cares more than average. We call ourselves Accreditation Nerds, but our customers are Accreditation Nerds, too. This community lifts each other–in skills and spirits.
These components that define ACHC are constant; they’ve been present for 40 years and counting. They are also what defines smart, modern accreditation: Programs that support stability today while helping organizations prepare for what comes next.
LEADERSHIP TEAM
José Domingos PRESIDENT AND CEO
Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES
Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
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the smart, modern choice
Listening as a quality strategy Exceptional service doesn’t happen by accident. It happens when an organization decides that feedback is not a formality, but a source of direction.
As ACHC President and CEO José Domingos has shared, the organization’s customer-focused approach required alignment across every role. “It doesn’t matter who you call,” he said. “They understand the mission.” Following this shift, customer satisfaction scores increased by 6% in one year and are now consistently 31% higher than they were in 2013. There’s a lesson here for any organization committed to quality. Feedback shouldn’t sit in a report. It should move through a process. That’s quality improvement in its most practical form: Listen carefully, respond honestly, and keep building something better.
In 2013, ACHC’s mission shifted. Accreditation and related education remained central to what we do, but we decided to shine a light on how we accomplish those things. Our mission refocused on providing the best possible experience throughout the entire accreditation process. That shift led to the creation of ACHC’s “Escalation Process,” a structured method for listening to customer
with their teams, ACHC created videos, process documents, and templates that could be revisited after the moment had passed. Some improvements required more than refinement. During the COVID-19 pandemic, traditional survey methods were disrupted, but healthcare organizations still needed the oversight and feedback provided by accreditation. ACHC became the first
What is NPS?
Net promoter score (NPS) is a widely used gauge of how likely customers are to recommend an organization. At the heart of NPS is a simple question: On a scale of 1-10, how likely are you to recommend our service to a friend? Scores from 0-6 are considered Detractors. Scores of 7-8 are considered Passives. Scores of 9-10 are considered Promoters. NPS is calculated by subtracting Detractors and Passives from promoters, yielding a score from -100 (all Detractors) to +100 (all Promoters).
accrediting organization to implement and deploy a virtual survey process approved by Medicare for certain programs. As customers began navigating that new process, they told us where additional clarity was needed. ACHC responded with stronger pre survey
feedback, triaging the customer experience, investigating less than
excellent interactions, and taking action to resolve or prevent it from happening again. Since 2013, ACHC has
reviewed more than 800 escalations and achieved nearly 300 improvements as a result of this process. Those improvements are not abstract. They show up in practical ways. When customers shared confusion about who to contact after an ACHC Account Advisor changed roles or went on leave, ACHC refined the reassignment process so organizations could be notified in advance and connected more smoothly to the right person. When organizations needed clearer guidance around distinction surveys, ACHC clarified record selection instructions. When customers asked for more accessible ways to share information
excellent world class
needs improvement
good
education, advanced communication, and
-100
0
50
70
100
practical guidance to help organizations prepare for the technology, expectations, and flow of a virtual survey. The result is reflected in ACHC’s customer satisfaction and Net Promoter Score performance, which are considered exceptional and best in class across all industries. But the score isn’t the point. The point is what the score represents: customers felt heard, supported, and confident enough in their experience to recommend ACHC to others .
According to Satmetrix, an NPS score above 0 is considered “Good,” 50+ is “Excellent,” and 70+ is “World Class.” The average US company NPS is 10.
As of January 2026, ACHC’s NPS is 81.
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community care
a conversation with
Vice President, Community Care Services Matt Hughes
You mentioned hiring Accreditation Nerds... The term makes us laugh, but in all sincerity,
But ACHC believes that accreditation shouldn’t be a burden, or worse, something to be feared. It should be an ongoing, supportive process that lasts throughout the accreditation cycle. We’re not outsiders. We’re your partners. We’re invested in your success. And we prove that by responding quickly to questions and connecting providers directly with experts. We take the time to hone our communications so they’re clear and concise. We find creative, engaging ways to teach new concepts in our workshops. Over time, those efforts have shifted the perspective of a lot of have-to organizations out there. Now they see accreditation as a critical path to improvement and a genuine value to their operations.
that’s exactly who we are. We’re unapologetically passionate about accreditation, quality, and compliance. Of course, hiring competent people is nonnegotiable. Our customer-facing staff—clinicians, regulatory coordinators, account advisors, customer care specialists— are the best in the business. ACHC’s program expertise is unmatched, employees who embody our culture that keeps the customer’s best interest in mind. Our people are personable hands-down. But expertise alone isn’t enough. We value
Matt Hughes joined ACHC in 2007 as an accreditation manager. Over time, his role increased in scope and responsibility, from business development to corporate strategy. In his current position, Matt guides the trajectory and development of ACHC Community Care Services which include nursing programs for home-based care, plus supportive services including home medical equipment and pharmacy. We sat down with Matt to get his take on what it means to offer smart, modern accreditation.
Looking ahead, how will ACHC continue making an impact?
Matt, your career has grown alongside our organization. How has that shaped your perspective? Watching ACHC develop over time taught me that true, meaningful progress is incremental. Change doesn’t happen overnight but strategic thinking and deliberate action lead to better processes, better products, and better outcomes. I’m a big believer in continuous quality improvement—the entire process, start to finish— because I’ve witnessed it. I know it works. What does ongoing improvement look like behind the scenes at ACHC? First and foremost, we listen. We’re constantly collecting and evaluating customer feedback alongside our internal quality processes, and that input has driven improvements across every part of our business.
But I think our commitment to improvement is also reflected in how we invest. We invest in new programs. We invest in maintaining ISO accreditation. We invest in hiring the right people—Accreditation Nerds! For the past year, our most significant investments have been in technology and infrastructure. We’ve been developing a new accreditation platform from the ground up. Our goals were better account management on our end and a more seamless experience on the customer end. After a lot of research, we concluded that building the kind of interface we envisioned meant developing software specific to ACHC. Now, as Navigator is being rolled out in phases, our in-house teams and our customers are benefiting from much
Our foundation is strong. For example, when CMS changed DMEPOS requirements, we were forced to pivot. We adjusted our process, our systems, our accreditation agreements, resources, everything. And we accomplished it quickly, because we have the corporate structure to make changes and meet expectations for regulatory agencies and for customers. As we look to the future, we’re asking questions. How can we help organizations become even more committed to improvement? How can our teams provide even more support? How can we partner with others to create even better solutions? We’re looking at how we can leverage technology, keep listening to our customers, and take our mission to the next level. I’m excited about what comes next.
and approachable. If a candidate isn’t open to engaging with others, they’re not the right fit.
How has ACHC worked to change the landscape of accreditation? Some see accreditation as a want-to, others as a have-to. The want-to set isn’t required to become accredited but choose to do it voluntarily. The have-to contingent seeks accreditation to meet regulatory or payor requirements. Have-tos usually see accreditation as an obstacle to overcome. They feel like the healthcare police are coming in to tell everyone what they’re doing wrong. We understand that the idea of an outsider coming in to evaluate your processes is uncomfortable.
better data access and transparency. Simultaneously, we’ve built a corporate headquarters designed to inspire
creativity. It’s full of design elements that encourage our staff to collaborate, to come up with new ideas, and to be innovative.
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community care
Community Care Accreditation Programs
behavioral health
In a field where collaboration is essential, accreditation provides a consistent framework for delivering care that is structured, responsive and coordinated across disciplines, services, and settings. ACHC Behavioral Health Accreditation reflects that complexity, offering service options that align accreditation with how each organization delivers care. Whether focused on outpatient support, stabilization, residential treatment, or integrated care, standards emphasize safety, continuity, emergency preparedness, and treatment coordination. associated distinction: » Telehealth
Our accreditation programs address the continuum of care from organizations providing supplies and support for activities of daily living to facility-based acute care and long-term residential care. ACHC Standards for each program are selected to align with the scope and acuity of services provided.
Assisted living communities are built around quality of care and quality of life. That balance requires coordination across clinical services, daily operations, and resident experience. ACHC Assisted Living Accreditation provides a structured framework for consistency by supporting staff education, operational alignment, and continuous improvement across services. From care planning to dietary coordination to daily routines, standards contribute to resident safety and well-being. For multi-site organizations, accreditation helps establish measurable benchmarks across communities. For independent providers, it offers nationally recognized validation of quality and accountability. associated distinction: » Outcomes assisted living Proving the Value of Accreditation From 2022 to 2025, ACHC participated in a statewide study led by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research to evaluate the impact of accreditation in assisted living settings. The study examined workforce stability, resident outcomes, care coordination, medication management, and person-centered care. Across these areas, one finding stood out: accreditation creates structure. Participating organizations demonstrated stronger alignment in care processes and more consistent approaches to quality improvement. Accreditation helped shift teams from reacting to issues to proactively strengthening operations. In assisted living, where quality is experienced directly by residents and families, that distinction matters. Small improvements, applied consistently, can become part of the culture. Over time, that is where quality takes root: in the daily decisions that support residents, families, and staff.
dentistry
Mobile dentistry expands access by bringing care directly to patients in schools, long-term care settings, and community environments. ACHC Dentistry Accreditation evaluates the safety, consistency, and quality of services delivered outside traditional dental offices. Standards address infection prevention, equipment use, and coordination with partner facilities.
dmepos
DMEPOS providers serve nearly every healthcare setting, delivering equipment that supports recovery, independence, and quality of life.
Today, the industry is navigating increased uncertainty following recent CMS changes. ACHC remains strongly committed to meaningful, CMS-aligned accreditation that strengthens organizations over time. ACHC DMEPOS Accreditation reflects real-world operations by supporting patient education, documentation, and safe use of equipment across delivery models. In an ever-changing environment, providers need more than a checklist. They need a steady, practical framework that helps them adapt, maintain compliance, and continue moving forward with confidence. associated distinctions: » Clinical Respiratory Patient Management » Custom Mobility
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ACHC Home Infusion Therapy Accreditation is required for organizations seeking Medicare reimbursement for the administration of infused medications. Standards ensure appropriate oversight, including physician involvement in the plan of care. Accreditation provides clarity in a complex care model, supporting safe, compliant, and coordinated service delivery. home infusion therapy
This year, ACHC brought home health and hospice surveyors together for onsite training and knowledge sharing. The sessions combined standards review with real-world insights from the field. With sessions led by ACHC experts, the training reinforced a simple idea: High-quality care is not supported by standards alone. It is supported by the people who apply them with consistency, judgment, and purpose. Improvement is deeply human work. When surveyors learn from one another, share what they’re seeing in the field, and align around practical education, that knowledge carries forward to the organizations they support. Continuing Surveyor Education
home care
Home care is built on relationships. Care is delivered over time, often becoming part of a client’s daily life and support system. ACHC Home Care Accreditation supports agencies providing non-Medicare, private duty services. Standards focus on documentation, coordination, and operational integrity, helping ensure care is delivered consistently and safely. Accreditation provides a framework that helps agencies strengthen processes while maintaining the flexibility that defines home-based care. associated distinction: » Palliative Care » Telehealth
hospice
Hospice care requires clarity, compassion, and coordination at every stage. ACHC Hospice Accreditation supports interdisciplinary care aligned with Medicare Conditions of Participation. This year, ACHC once again earned the maximum six-year renewal of deeming authority from CMS, confirming confidence in the program’s ability to meet national standards. As expectations evolve, ACHC helps organizations strengthen processes while maintaining focus
on patient-centered care. associated distinctions: » Age-Friendly Care » Palliative Care » Telehealth
palliative care
Palliative care focuses on supporting patients’ quality of life, at any stage of illness. ACHC Palliative Care Accreditation recognizes organizations delivering coordinated, patient-centered care that addresses physical, emotional, and social needs.
home health
ACHC Home Health Accreditation Standards align with the CMS Conditions of Participation. Distinctions provide additional quality validation for specialized services. In 2026, ACHC’s continued approval from CMS as a national accrediting organization— extended through 2031—reaffirmed the strength of the program. associated distinctions:
Available as both a standalone accreditation and a distinction, the program provides flexibility based on the scope of services. In a model built on advocacy and service coordination, accreditation supports consistency across every touchpoint. associated distinction: » Telehealth
» Palliative Care » Telehealth
» Age-Friendly Care » Behavioral Health » Outcomes
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community care
pharmacy inspection services ACHC conducts nonresident pharmacy inspections for select state boards of pharmacy, supporting licensure for pharmacies operating across state lines. In 2026, ACHC expanded this capability with approval in Massachusetts, with continued efforts to support additional states.
pcab ( compounding pharmacy )
New Opportunity in Sterile Compounding
PCAB, a brand of ACHC, remains the recognized benchmark for excellence in compounding pharmacy practice.
In the new ACHC headquarters, a simulated cleanroom provides a real-world environment for education, and hands-on training in sterile compounding. In June 2026, ACHCU hosted its first in-person Sterile Compounding Certification Programs in this space, giving participants the opportunity to earn a credential by learning in an environment that mirrors the realities of sterile compounding work.
Standards ensure compliance with USP requirements while supporting quality, safety, and consistency across sterile and nonsterile operations.
renal dialysis
Renal dialysis is long-term care in its truest form, requiring consistency, education, and patient engagement. ACHC Renal Dialysis Accreditation supports organizations delivering care across settings, including home-based models. Standards emphasize safety, coordination, and patient- centered care. distinction opportunity: » Telehealth certification opportunity: » Long-Term Care Dialysis
pharmacy
Pharmacy services continue to grow in complexity, encompassing clinical services, patient education, specialty therapies, and coordination across care settings. ACHC Pharmacy Accreditation supports organizations of all sizes with a flexible framework that aligns with real-world practice. Backed by deep pharmacy expertise, the program helps organizations improve with a deliberate focus on quality, safety, and patient care. associated distinctions:
sleep
Sleep testing coordinates scheduling, testing, interpretation, and follow-up care. ACHC Sleep Accreditation supports organizations offering services in the lab, in the home, or both. Standards align with Medicare requirements while allowing flexibility for evolving care models. As home sleep testing continues to expand, ACHC remains focused on supporting organizations with clear, relevant accreditation that reflects how sleep care is delivered today.
» Oncology » Rare Diseases and Orphan Drugs
» NEW Immunoglobulin Therapy » Infectious Disease Specific to HIV » Nutrition Support
Guidance for pharmacies supplying DMEPOS
Pharmacies pursuing DMEPOS accreditation often do not have the luxury of a dedicated compliance team. For Jeffrey Reses, RPh, HDDP, ACHC Senior Pharmacy Clinical Liaison, building that knowledge is part of building a stronger operation. It takes time, but it pays off in confidence, consistency, and fewer surprises. Here’s his guidance:
There’s always going to be change in sleep services: new technology, new expectations, new ways of delivering care. The organizations that do well are the ones that don’t just react to those changes but use them as an opportunity to strengthen how they operate and care for patients. When you approach change that way, quality isn’t something you check off. It’s something you keep building over time. — Dawn Clayton ACHC Accreditation Sleep Specialist
■ Look up DMEPOS items to determine the LCD requirements. ■ Read the Medicare Integrity Manual. Yes, the entire thing. ■ Get familiar with the Pharmacy Exemption Fact Sheet. ■ Read through the 855-S with close attention to detail.
■ Sign up for the MLN Connects ® Newsletter for Providers, Suppliers, Billers and Coders. ■ Make sure you understand the DMEPOS Supplier Standards, whether you’re with NPEAST or NPWEST, and which products you’re supplying. Know the difference between non-accredited products and products requiring accreditation.
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the smart, modern choice
Accreditation Nerd Newbie, Apprentice, or Trailblazer: Which one are you? Last year, we introduced you to the Accreditation Nerd—an individual who is proudly, unequivocably interested in (one could say passionate about) compliance with accreditation standards. Since then, at trade shows, conferences, and workshops we’ve met hundreds of unapologetic Accreditation Nerds, as obsessed as we are with continual growth and quality improvement. But Nerds are not a monolith. Accreditation enthusiasts have a wide range of experience levels, backgrounds, and settings. That’s why we created Accreditation Nerd “levels” that correspond with phases of learning. Newbies start with the basics, Apprentices upgrade their skills, and Trailblazers take on knowledge-sharing and leadership. Your team is probably a mix of all three. Nerds are made, not born! We want to help you develop your staff into a crack team of Accreditation Nerds. First, you need to figure out where you stand. Developing Your Team. Let’s be honest. You need to develop your staff. At a minimum, it’s a requirement. Training and competencies are addressed by ACHC Accreditation Standards as well as many state/federal regulations. However, smart, modern organizations know that a well-trained team is integral to patient safety, positive outcomes, and growth. As an education-first accreditor, providing easy access to resources and experts is our specialty. We want to empower you with knowledge so you can avoid deficiencies, but perhaps more importantly, to share that knowledge with your colleagues.
THE Education Event for Health Care
In 2026, we hosted the 5 th annual ACHCU Academy at a beautiful beachfront resort. Attendees, speakers, and exhibitors gathered to deepen their knowledge of healthcare accreditation in a picture-perfect setting. Think sunny skies, warm ocean breezes, and glorious walks along the shoreline between sessions. Except… That’s not what happened. Instead of endless sunshine, Florida delivered fog, rain, and temperatures hovering around 50 degrees. Sandals and swimsuits gave way to jackets and windbreakers.
And then something remarkable unfolded. S’mores replaced sunsets, and laughter replaced perfect weather. Conversations lingered. Networking became more personal. Unexpected circumstances created stronger connections and deeper relationships.
As we look ahead to Nashville in 2027, we’re excited for the music, nightlife, and energy of the city. But 2026 Academy reminded us that the true spirit of the event isn’t the destination. It’s the community.
Take the quiz here. Explore the next pages for more.
DISCLAIMER: The ACHC Accreditation Nerd Quiz is for entertainment purposes only. While it may feel eerily accurate and/ or mildly confrontational, it is not a clinical diagnosis. If your results are wildly inconsistent with your deeply held nerd identity, we invite you to review every description and select the one that best aligns with your inner compliance geek.
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the smart, modern choice
Empower your team. develop nerds.
The ACHC Did You Know? e-newsletter contains industry updates, upcoming events, and a link to a featured article written by an ACHC expert. Instead of receiving sporadic, disjointed communications, your inbox stays clutter-free with one concise email. Use this resource to increase awareness, mark your calendars for upcoming webinars, and foster compliance conversations with your team.
Accreditation Nerd Newbies aren’t necessarily new to healthcare, but the accreditation process is unfamiliar territory. These team members benefit from an environment that encourages questions.
Accreditation Nerd Trailblazers have deep knowledge and are skilled at sharing it. Typically leaders, educators, and/or trainers, Trailblazers value clear communication and shared accountability for compliance.
tips to develop nerd newbies: » Explain the basics, reward curiosity, and give them attainable goals. » Use flash cards to define common terms and/or processes. They work!
» “Wrong answers only.” Kick off a regularly scheduled huddle or meeting with a question based on an accreditation standard. Encourage participation by limiting the response to “wrong answers only.” By discussing what isn’t compliant, everyone learns what is.
tips to develop nerd trailblazer: » Empower them to play a major role in accreditation preparation. Cultivate their communication skills. Embrace their innovation, creativity, and curiosity.
Accreditation Nerd Apprentices are grounded in the basics and have learned to apply general concepts to specific situations. Next comes understanding the how and the why behind processes and requirements.
» Treat achc.org as a trusted companion. Use FAQs, publications, and articles
for inspiration to post daily trivia questions for your team. Have fun with it! » Conduct a mock survey. Trailblazers are best positioned to organize a practice run. Assign a “surveyor” and rotate the role across departments. Focus on smaller sections of the standards and practice weekly or monthly.
The Quality Review edition of Surveyor reveals common survey deficiencies alongside concrete tips for compliance. Use this resource to generate ideas for mock surveys and “spot the deficiency” pictures for training purposes.
tips to develop nerd apprenctices: » Assign hands-on projects when possible. » Create opportunities to participate in data analysis, record audits, process improvement, and/or reports. » Fact-finding mission. Task Nerd Apprentices with a review of checklists or documents used by your organization. Ask them to evaluate
accuracy and formulate a timeline to make updates. By searching for the answers, they’ll gain insight into new and different processes.
Think of the “Articles” section of achc.org as a library. Search and filter for deep dives into standards,
guidance on regulatory changes, interviews with ACHC experts, and more. You’ll find a wide range of pieces written by subject matter experts—all of whom have been in your shoes. Our knowledge bank continues to grow with their unique perspectives. Use this resource to find ideas for checklists, topics for meetings or huddles, and practical tips for compliance.
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community care
Distinction Programs Distinctions recognize organizations that build beyond the foundation of accreditation. They offer a way to validate focused expertise, strengthen specialized services, and demonstrate a commitment to continuous improvement in areas where patients often need additional support.
Nerd Development: Step-by-Step
age-friendly care
Catherine Sierra joined ACHC in 2012 and has advanced through key positions within our Community Care division. In her current role as Associate Director, Customer Experience , Catherine’s team is skilled at supporting customers with personalized guidance. Here’s how they do it.
The ACHC Distinction in Age-Friendly Care focuses on aligning care decisions with patient goals while reducing risk, confusion, and unnecessary interventions. Built around the “4Ms” framework—What Matters, Medication, Mentation, and Mobility—this distinction recognizes organizations delivering coordinated, evidence-based care tailored to aging
populations. eligibility: » ACHC Home Health Accreditation » ACHC Hospice Accreditation
After over a decade of speaking with organizations seeking accreditation, I have a good sense of what our customers really want. They’re looking for a team to support and advise them. They want to work with people who know what they’re doing, and who care about what they’re doing. The last thing they want is a generic answer with no actual knowledge behind it. Because now they’ve made a major business decision, or missed a regulatory deadline, based on an answer from a person who wasn’t invested in their success. That’s why I prioritize training and professional development for my team. The more equipped ACHC Account Advisors (AAs) are, the more they can answer questions with intention. The more they become subject matter experts on the accreditation process, the better they will serve our customers. For me, it’s not process improvement. It’s process empowerment . For our team, the best method for learning is hands-on experience. Learning by doing is far more successful than just listening or reading. Every new team member gets one-on-one time with a trainer, so they can observe and participate in situations as they’re happening. Our Newbie AAs start by learning the baseline accreditation process. If they know the baseline, they’ll also begin to notice when a step doesn’t look right. Gradually, they experience the nuances
of what each organization needs. Nuance is important, because ACHC Standards are built to serve a wide range of business models. Variations are inevitable. But once an AA handles a new scenario, they know what to do next time. For AAs, the Apprentice level is akin to becoming a “team lead.” They’ve mastered the steps of the accreditation process and understand the why behind it. They’re ready to apply what they’ve learned and focus on communication. Team leads are the first point of contact for customer concerns, so they build skills in active listening and critical thinking. They relay important information to the rest of the team and are responsible for training Newbies. Team leads also learn how to identify opportunities for improvement with customer-facing documents and staff education. ACHC Customer Experience Managers are our Trailblazers . They start as Newbies, move through the levels, become experts, and then—when the timing is right—they develop into managers, mentors, and educators. They know accreditation and they know their teams. The new challenge is learning how to lead. As leaders, it’s absolutely our responsibility to get our teams to the next level. We want to be challenged and motivated to do more and get better. Adopting that mentality means that everybody—managers, support roles, team leads, new employees, seasoned staff—is on the same path, side by side. We’re not satisfied with “good enough.” We’re lifting each other up.
behavioral health
This distinction recognizes home-health providers integrating behavioral health into their service offerings. Standards support coordinated care for patients
with mental illness, substance use disorders, or intellectual and developmental disabilities, strengthening communication, continuity, and outcomes across the care team and their clients. eligibility: » ACHC Home Health Accreditation
This distinction recognizes providers delivering ongoing respiratory care outside the hospital setting. Standards emphasize a team-based approach to assessment, disease management, and patient education, supporting individuals with acute or chronic respiratory conditions through coordinated, continuous treatment. eligibility: » ACHC DMEPOS Accreditation (Home Medical Equipment service) clinical respiratory patient management
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This distinction recognizes providers delivering complex rehabilitation and assistive technology services, with a focus on individualized solutions and access to support when patients need it most. eligibility: » ACHC DMEPOS Accreditation (Complex Rehab service) custom mobility
This distinction recognizes providers delivering parenteral and enteral nutrition with a focus on specialized pharmacy operations, coordination of care, and patient safety. eligibility: » ACHC Pharmacy Accreditation (Infusion Pharmacy service) nutrition support
Immunoglobulin therapy presents unique clinical and operational complexities, requiring careful oversight, monitoring, and coordination. immunoglobulin therapy
oncology
Distinction in Immunoglobulin Therapy: Why now? As indications for immunoglobulin therapy expand, variability in how it is delivered can introduce risk. Differences in clinician training, patient monitoring, and care coordination all impact outcomes. This distinction brings structure to that complexity. Developed in partnership with the Immunoglobulin National Society (IgNS), the industry-first Distinction in Ig Therapy aligns IgNS clinical expertise and ACHC’s expertise in organizational accountability in response to a clear need: stronger, more consistent standards to guide clinical practice and ensure patient safety across the continuum of care. More than a recognition, it represents a shift toward greater consistency, stronger oversight, and a higher bar for quality in immunoglobulin therapy.
Oncology therapies demand careful handling, monitoring, and coordination across care teams. This distinction recognizes pharmacies managing cancer-related medications with a focus on safety, toxicity awareness, and collaboration to support patient outcomes throughout treatment. eligibility: » ACHC Pharmacy Accreditation (Specialty Pharmacy service)
This distinction recognizes pharmacy organizations that meet advanced standards for safety, consistency, and quality in Ig therapy, based on evidence-based practices developed in collaboration with the Immunoglobulin National Society. eligibility:
outcomes
This distinction recognizes organizations using data to drive continuous quality improvement. By analyzing performance across key domains, providers can identify opportunities, establish benchmarks, and strengthen care delivery through measurable, sustained improvement. eligibility:
» ACHC Pharmacy Accreditation (Specialty or Infusion Pharmacy services)
» ACHC Home Care Accraccreditation » ACHC Home Health Accreditation
» ACHC Hospice Accreditation
This distinction recognizes pharmacies with specialized processes for managing HIV therapies. Standards emphasize adherence support, coordinated care planning, and collaboration between the pharmacy, provider, and patient, helping optimize outcomes while managing the complexities of treatment. eligibility: » ACHC Pharmacy Accreditation (Specialty Pharmacy service) infectious disease specific to hiv
palliative care
Palliative care focuses on improving quality of life across the continuum of illness, regardless of life stage. This distinction recognizes organizations delivering coordinated, patient- and family- centered care that addresses physical, emotional, and social needs while supporting informed decision-making. eligibility:
» ACHC Home Care Accreditation » ACHC Home Health Accreditation » ACHC Hospice Accreditation
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community care
Unlike other ACHC Certification programs, Long-Term Care Dialysis requires ACHC Renal Dialysis Accreditation. Standards are designed to promote an elevated care model that delivers optimal patient safety and enhances the continuum of care and collaboration between the dialysis facility and the long-term care facility (SNF/NF). long-term care dialysis This program confirms that your staffing agency meets recognized standards for credentialing, training, and evaluating competencies of healthcare professionals prior to placement, and tracking those placements. In an era of staffing shortages, third-party validation demonstrates your commitment to providing a solution. healthcare staffing services Certification Programs Certification confirms quality in specific programs within an organization. These are programs treating a subset of the organization’s patient population. Generally, the program is of sufficient scope to require formal support from the organization’s governing body. The certification survey is limited to review of the specialty service and how it integrates into the organization as whole.
Managing therapies for rare diseases requires specialized processes, coordination, and data tracking. From access and dispensing to monitoring and outcomes reporting, this distinction recognizes pharmacies that partner with manufacturers and providers to support patients through the full treatment journey. eligibility: » ACHC Pharmacy Accreditation (Specialty Pharmacy service) rare diseases and orphan drugs
telehealth
Telehealth expands access while introducing new considerations for credentialing, monitoring, patient engagement, and documentation. This distinction recognizes organizations delivering care through technology-enabled models. eligibility: » ACHC Behavioral Health Accreditation
» ACHC Hospice Accreditation » ACHC Palliative Care Accreditation » ACHC Renal Dialysis Accreditation
» ACHC Home Care Accreditation » ACHC Home Health Accreditation
telehealth
Organizations that focus on delivering care and services through technology-based patient contact are eligible for Telehealth Certification. Telehealth is also available as a Distinction under Ambulatory Care, Behavioral Health, Home Care, Home Health, Hospice, Palliative Care, and Renal Dialysis Accreditation. The choice of certification or distinction is based on whether the program stands alone or is a considered a service within an accreditation-eligible organization.
Time to Cowboy Up
NASHVILLE, TN | March 8 – 10, 2027 Save the date.
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acute care
Could you elaborate on the connection between ongoing improvement and accreditation?
About day one... Let’s rewind. Were you always interested in accreditation?
Vice President, Acute Care Services Patrick Horine a conversation with
I left “my” AO because I thought I could do more at ACHC. I responded to the way José (Domingos, ACHC President and CEO) talks about the idea of quality improvement vs. “checking a box.” Some providers just want to get through the survey and move on. And those organizations might be providing good care, but they’re not a good fit for ACHC. We want to show you what your issues are so you can fix them to be a better organization. If you want to address the root causes and minimize your risk... If you’re committed to ongoing improvement and collaboration... If you want competent, empowered, confident staff... ACHC is the right fit. I had a great call with a hospital CEO recently about their survey with us. He said his team
I was emphatically not interested in accreditation, healthcare, or really anything except having a good time, which is why I was... “uninvited”
from college. So then I needed a job and the local hospital was hiring. I went to work in the kitchen, delivering the trays to the floors and cleaning them off when they were done. I loved it. I loved talking to the nurses, the doctors, the patients. I loved the relationships, the teamwork, the environment, all of it. I knew immediately I’d found my direction. I went back to college, and eventually to graduate school for hospital administration. My residency was in quality and accreditation. That experience gave me the kind of insight I never would have gotten in the classroom. Every team is involved with the accreditation process. There’s no better way to get exposure to all aspects of an organization. From there I went into business development and operations, and by the age of 29 I was a hospital CEO. So you were “uninvited” from college... and ended up as a CEO? That’s right! I had no business being a CEO at that age, but the thing is, I knew a lot about working in a hospital. The choices I’d made, including the failures, led me to that. It made sense. That’s what I mean about a quality mindset. Life is full of potential paths, and for the most part there’s no wrong choice. Just make one and see where it takes you. If it doesn’t work out, there’s a reason for it. That’s what has worked for me personally, and it’s why ACHC will keep growing. Our entire philosophy is built on adapting and evolving, for ourselves and for our customers.
Before joining ACHC in 2022, Patrick served as President and CEO of DNV Healthcare USA Inc., where he successfully steered the development and launch of a hospital accreditation program. Patrick left that role to lead ACHC’s division of Acute Care Services in 2022. Patrick shares the story—and it’s a good one—of how he came to be involved in accreditation and why he’s so dedicated to driving quality through innovative approaches.
Patrick, you came to ACHC with a unique perspective; you had actually built another accrediting organization from scratch.
Because I knew what I had seen in the hospital. The accreditation surveyors would come in and regurgitate the standard with no explanation. And I’d think, “Hey, I can read the standard. How about some guidance and interpretation?” And where were they after our approval? For all the money we were investing in that accrediting organization, where was their investment in us? It seemed obvious there was a gap in the industry. I decided to build a viable alternative for hospitals looking for more than cookie-cutter, yes/no answers.
complimented the responsiveness of their ACHC Account Advisor and the clinical guidance they received along the way. But more than anything, he appreciated that we didn’t come onsite just to identify
ACHC had a solid foundation with community- based services, and I came on board to help develop their acute care division. I felt a little bit like I had seen my baby grow up, and
here I was about to raise another kid. Except ACHC didn’t have a baby, they had a teenager that just needed some creative guidance to finish growing. I wasn’t starting from ground zero.
deficiencies and say, “Gotcha!” That kind of feedback really means a lot to me, because it’s what I truly want organizations to understand. Accreditation can be more than the survey. What happens between surveys is actually more important. If an organization has good processes in place, the accreditation survey should be a non-issue. No panic, no last-minute crunch time—just business as usual. Hospitals deserve an accreditation experience that improves processes and ensures safe patient care. That’s been my personal quest from day one.
What lessons did you learn from that experience that you still use today?
When did you decide to create an AO? How did that decision come about? I was in hospital administration, which I loved, but I was ready for a new path. So I left to join a consulting firm. They wanted to pursue CMS deeming authority to become a hospital accrediting organization. To which I said, “You’re nuts.” But then I said, “Let’s do it.”
Be patient and persistent. Keep your momentum, even if it’s one tiny baby step each day. You’re still moving forward. Good decision-making really boils down to a quality mindset. Tackle the issue,
see what works. Then take what works and leave what doesn’t. Rinse and repeat.
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acute care
Acute Care Accreditation Programs
With a comprehensive program that includes all levels of testing complexity, ACHC Clinical Laboratory Accreditation is built for medical office-based, hospital-based, and independent laboratories. When your lab achieves ACHC Accreditation, you obtain more than CLIA compliance. You also gain access to educational resources and clinical support throughout your two-year cycle. Visit labuniversity.org to earn CE credits with online courses and download tools to build your QC Program. clinical laboratory
acute care hospital
ambulatory care
critical access hospital
Your teams work hard to deliver the best possible care to your patients, and you deserve a respectful and positive accreditation experience that affirms and inspires quality in your work. Through educational surveys, expert guidance, and partnership, ACHC helps hospital staff better understand requirements and apply best practices effectively. Our comprehensive standards align with regulatory criteria while remaining flexible and adaptable to every organization’s size and scope. associated certifications: » Cardiac Care » Joint Replacement
Ambulatory Care Accreditation supports clinics that provide convenient, accessible outpatient services in both standalone and retail-based settings. ACHC Standards help organizations implement consistent practices, reinforce patient confidence, and establish trust as a non-emergency alternative in the communities they serve. associated distinction: » Telehealth
ACHC has decades of experience guiding new and existing CAHs through the accreditation process, but we’re also invested in your success beyond the survey. We’re committed to helping you ensure a stable future as you balance between your community’s needs and financial challenges. Through flexible pricing plans, educational resources, and responsive, accessible support, our sensitivity to the realities of rural health care set the tone for a partnership grounded in expertise and empathy. associated certifications: » Cardiac Care » Joint Replacement
» Stroke Care » Wound Care
ambulatory surgery center
Ambulatory surgery centers have different needs and timelines.
» Stroke Care » Wound Care
Both new organizations and existing ASCs benefit from a customizable, collaborative accreditation experience built to support a successful survey as well as continuous, ongoing improvement. We pride ourselves on a practical, educational approach guided by experts dedicated to helping you simplify and clarify your organization’s application of ACHC Standards. ASCs receive exceptionally responsive customer service and access to resources providing actionable, concrete tips for compliance. associated certification: » Joint Replacement
This unique accreditation program addresses the evolution of high acuity home-based care. “Hospital-at-home” services can be safe, high quality, and efficient alternatives to inpatient admissions. Provider eligibility is determined by staffing levels, applicable experience, and commitment to providing home visits at a frequency that supports an effective treatment plan. in-home hospital care
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