Final Rule Reduces Burden and Strengthens Patient Safety
The Centers for Medicare & Medicaid Services (CMS) is taking steps to improve healthcare quality and patient safety through enhanced oversight of Accrediting Organizations (AO). This final rule, Strengthening Oversight of AO and Preventing AO Conflicts of Interest, ensures that the organizations responsible for the oversight of more than 9,000 healthcare providers and suppliers use Medicare standards, and creates greater consistency between State Survey Agencies (SAs) and AOs in their respective survey processes. These changes will reduce provider burden, strengthen survey policies, and increase transparency.
“The work accrediting organizations do is vital, but it also raises an age-old question: who watches the watchmen? The answer is, we do,” said CMS Administrator Dr. Mehmet Oz. “With this new rule, CMS is advancing its commitment to upholding rigorous standards for accrediting organizations and ensuring the health and safety of American patients.”
Today’s final rule is designed to:
- Ensure AO accreditation standards continue to meet or exceed those of the Medicare program.
- Align accreditation and survey processes with CMS requirements.
- Confirm AO enforcement of CMS requirements.
- Reinforce that all accredited entities must deliver safe, effective care.
- Prevent AO conflicts of interest that may arise from related consulting services.
Additionally, the rule creates a brand new process for monitoring AO performance; establishes consistent standards, processes, and definitions; updates validation and performance systems; requires AO surveyors to take the same CMS training as SA surveyors; and reduces burden on SAs, AOs, and providers by streamlining the CMS AO validation process.
Certified facilities, whether surveyed by state agencies or AOs, must meet the same rigorous health and safety standards. The rule requires accreditation surveys be conducted without advance notice, ensuring consistency with previously established CMS policy.
The rule addresses longstanding concerns by prohibiting AOs from conducting mock surveys for providers they accredit before initial surveys and within 12 months of re-accreditation. This prohibition helps ensure consulting activities do not compromise the objectivity and integrity of the accreditation process. Additionally, variability in accreditation standards has led to inconsistent survey findings and enforcement across Medicare-certified facilities. This rule establishes clear, uniform requirements to eliminate ambiguity. By applying Medicare conditions and requirements as the baseline standards, CMS ensures the application of consistent safety requirements across facilities.
View the final rule on the Federal Register.
View the Fact Sheet.
