Accreditation Manual
CAHIIM Staff (top)
The Executive Director and Accreditation Staff provide programmatic support to academic faculties, administrators and to the public in several ways. They assist programs by answering questions, and providing consultation about Accreditation Standards and the accreditation process for developing and continuing programs. They counsel prospective and current students on issues related to accredited programs and curriculum and accreditation expectations.
The Accreditation Processes (top)
Accreditation by CAHIIM is a status that HI and HIM educational programs choose to apply for voluntarily.
Accreditation is a confirmation that the program is in compliance with the
CAHIIM Standards and Interpretations:
Health Informatics (HI) Masters Degree Program (adopted 2010)
HIM Masters Degree Program (adopted 2009)
HIM Baccalaureate Degree Program (adopted 2005)
HIM Associate Degree Program (adopted 2005)
The Sponsoring Institution (top)
When a specific campus confers the academic degree, the program will be recognized individually for CAHIIM programmatic accreditation. If accredited, each campus must complete the following process requirements: separate Self-Assessment, Site Visit, Annual Report and submit the Annual Accreditation Fee.
The steps for accreditation fall into two major categories: Initial Accreditation and Continuing Accreditation. The accreditation program review process is required for intent to open a program on another campus.
Initial Accreditation Process (top)
The Initial Accreditation Processing Fees:
Health Informatics Graduate Education Programs
HIM Graduate Education Programs
HIM Undergraduate Education Programs
CAHIIM Candidacy and Stages (top)
The Self-Assessment Process (top)
The Self-Assessment process is an essential part of the accreditation process and is designed to help the educational institution improve program effectiveness by identifying its strengths and weaknesses. The objectives of the Self-Assessment process is to provide qualitative as well as quantitative assessments of the program.
Careful review of the current program and evaluation of its goals and objectives, content, policies, administration, educational resources, and general effectiveness by faculty, administrative staff, advisory committee, and students is the best means of securing lasting educational improvements within any institution or program.
The Self-Assessment process serves the following functions:
• Demonstrates incorporation of the Standards into the Self-Assessment process
• Provides an opportunity for evaluation of the program, its goals, objectives and outcomes
A primary goal of the accreditation process (initial and continuing) is the development of a thorough understanding by an institution of its existing program and the needs of the community of interest, including potential students and employers. The results of such an analysis may be a reconfirmation of the present curriculum or recognition of the need to make changes, as well as provision of documentation of the current characteristics of the program.
The failure of a program to carry through this process and to develop a thorough Self-Assessment may result in rejection of a request for accreditation or the postponement of the Site Visit until an acceptable Self-Assessment is prepared for the Site Visit Team.
Self-Assessment Committee (top)
The Self-Assessment committee is of paramount importance in program evaluation and improvement. This interaction provides an opportunity for all those concerned with the program to participate in the evaluation process. The committee should be appointed by the Dean of the administrative unit in cooperation with the Program Director. CAHIIM recommends that the committee include representatives of the administrative staff, faculty, students, external program advisory committee, and from the professional practice experience sites. It should be chaired by the qualified Program Director. A Self-Assessment can be an effective instrument for change only if it is conscientiously conducted by responsible committee members with the full support of the administration, faculty, and students of the educational institution. The Self-Assessment committee meets initially to plan how the self-evaluation will be conducted and to assign individuals to gather information on specific sections of the Self-Assessment phase. One person, a Self-Assessment committee chairman, should assemble and approve the content of the Self-Assessment. When the plan of action has been determined, the Self-Assessment committee should meet regularly to discuss findings and to agree on document content.
It is critical that the chairman foster continuing communication among committee members throughout the Self-Assessment process. The committee should develop a time schedule for gathering preliminary information, holding regular meetings for discussion of findings, and developing the document. The Self-Assessment describes, in logical Standard sequence, the educational program as it exists, indicates the program’s strengths and weaknesses, develops strategies for correcting the weaknesses, and projects plans for future development of the program. The committee should ensure that information requested is accurate, substantive, and of high quality.
The Self-Assessment Document must indicate the way in which the educational program meets the stated requirements of the Standards and should be written so that those unfamiliar with the program will gain the following:
• Understanding of the philosophy, goals, and objectives of the educational institution and its HIM program.
• Understanding of the environment in which the HIM program operates, the learning resources available, and the learning experiences provided.
• Sufficient information about the curriculum to appraise it fairly in relation to its published description in the college or university catalog or bulletin, the stated program goals and objectives, and current educational Standards.
How to Apply (top)
All Applicants must register and submit an application using the CAS New Programs Link.
The Site Visit Process (top)
Site Visits are conducted to assure the accrediting organization that the educational program complies with the minimum Standards established for academic programs.
The Site Visit can provide the opportunity for faculty to consult with educational specialists; assist the institution in its continuing Self-Assessment process and improvement of the quality of instruction; and promote exchange of ideas between educators and practitioners of the profession.
The Site Visit process provides the opportunity to validate or clarify the contents of the Self-Assessment Document and to determine the extent to which a program complies with the Standards. The Site Visit is predicated on the Self-Assessment review process results prior to the Site Visit. The Site Visit Team is responsible for evaluating additional documentation provided to them during the Site Visit that substantiates their assessment and evaluation.
The Site Visit Team representing CAHIIM will make an in-depth analysis of the program in order to discuss the program with appropriate administrative officials and faculty members. The team will visit classrooms, practice laboratories, library resources, and online technical applications. In addition, the site visitors will have discussions with students enrolled in the program, advisory committee members, and other individuals associated with the program.
requested to be included in the Self-Assessment but should be made available during the Site Visit including: agreements, advisory committee minutes, faculty handbook, examinations and other course related materials (such as laboratory projects, research reports), and student files maintained by the Program Director.
Site Visit Team Members attempt to gain an appreciation, philosophy and objectives of the educational institution and the program. The Team endeavors to obtain sufficient information to understand the total educational program and to compare the program’s stated philosophy, goals, and objectives with the established standards.
The Site Visit is only one part of the review process and the Site Visit Team will make no assumption regarding the final outcome (accreditation status) of the program. Official notification of accreditation is the purview of the CAHIIM Board of Commissioners.
Site Visit Team and Selection (top)
The Site Visit Team is composed of up to 3 members representing CAHIIM. These individuals are qualified through education, experience and training in the process. A CAHIIM Representative will be included.
After site visitors are assigned, CAHIIM Staff notifies the Program Director of their names, addresses and phone numbers. Every effort is made to avoid any conflict of interests in the assignment of a Site Visit Team. However, if a conflict exists, please notify the Accreditation Operations Manager immediately. Once a site visit date is identified for a program applicant, the date will be posted at the Schedule of Site Visits on the CAHIIM web site.
Hotel And Travel Information (top)
All health information management education programs are responsible for all direct costs of the site visit, including travel, hotel, local transportation to/from airport, hotel and the campus, and meals.
Air Travel Arrangements (top)
Site visitors are responsible for making their own travel arrangements through the AHIMA/CAHIIM travel agency. Approximately 30 days after the Site Visit, AHIMA Financial Services Staff will invoice the institution for all reimbursable expenses that have not been direct-billed to the applicant institution/HIM program.
Hotel Reservations for all Site Visitors
The following requirements must be followed:
• Single room reservations must be made by the sponsoring educational institution and if possible, expenses direct-billed to the institution.
• Hotel reservations should be guaranteed for late arrival for the day prior to the Site Visit, with checkout on the second day of the site visit. Written or e-mailed hotel confirmations should
be provided to Site Visitors and the CAHIIM Accreditation Operations
Manager.
Local Ground Transportation:
For local ground transportation, costs can be reduced if faculty or campus transportation can be provided for site visitors to and from the airport, hotel and campus. Otherwise, a rental car will be secured for the site visitors, if necessary. If a shuttle is available to and from the airport please provide this information to your Site Visit Team.
If there is a campus map and/or other information about the city, e.g., city map, restaurant guide, etc., or any other information you think the site visitors/observer might find useful, please forward copies of this to all Site Visit Team members.
The Continuing Accreditation Process
Continuing Accreditation Processing Fees
Annual Program Assessment Report (APAR) (top)
All newly accredited and continuing programs complete the documentation of their program learning outcomes and assessment process. The Annual Program Assessment Report (APAR) is required by the CAHIIM for Maintenance of Accreditation.
Evidence of academic program outcomes is an important dimension of accreditation review. The higher education community, policy makers, and students are seeking information about what students achieve as part of the consideration of the quality of accredited programs and institutions. Accrediting organizations around the country are responsible for establishing clear expectations that institutions and programs will routinely develop, collect, interpret, and use evidence of student learning outcomes. CAHIIM has based the Standards for Accreditation of Health Information Management Programs on the premise of outcomes-based assessment. The APAR is designed to capture this information as outcomes-based evidence in several major categories, identified in the APAR System.
APAR Online Resources Page and Process Description (top)
Awarding Accreditation (top)
Initial or Continuing Accreditation may be awarded when the accreditation review process confirms that the program is in compliance with the Standards. Graduates are not allowed to apply for the AHIMA RHIA or the RHIT certification exam until the program has received the official letter awarding Initial Accreditation from CAHIIM. It is the responsibility of the program to inform the graduates of the accreditation status of the program.
CAHIIM Accreditation is not time limited. Once achieving accreditation, the program’s accreditation continues until there is cause to change its status. The program will submit the APAR annually in conjunction with any assigned Focused Review or the assigned 10 year validation Site Visit.
Accreditation Categories
Accreditation is based upon whether the standard compliance has been Not Met Categories
or Partially Met. These points are added up to determine the following categories of accreditation used by CAHIIM to confer a program’s compliance level with the Standards:
• Accreditation (Initial and Continuing)
• Probationary Accreditation
• Administrative Probationary Accreditation
CAHIIM determines accreditation after the institution has been given an opportunity to respond to the findings and results of their site visit.
Due Process Procedures: If a final adverse decision is made under:
• Accreditation Withheld
• Accreditation Withdrawn
the sponsoring institution of an educational program may withdraw its Application for Candidacy, submit a request for Voluntary Withdrawal (Continuing Programs only), or request Procedural Reconsideration before the Board of Commissioners' final action.
Determining Accreditation Status (top)
When the CAHIIM Board meets to determine the Accreditation Status of any program, they reach their decision based upon an internal Rating Scale that is used to achieve process consistency. Each Standard has been allocated a validated number of points.
The Progress Report Process (top)
A satisfactory Progress Report may be required to be sent to CAHIIM by the due date in the CAHIIM award letter. The Progress Report on CD of jump drive format should be submitted to the Accreditation Operations Manager including all items of evidence that substantiates the corrective action. The purpose of the Progress Report is to give the program an opportunity to demonstrate resolution of deficiencies before its next comprehensive review. Programs should note that if a satisfactory, ‘Second Progress Report is not submitted within the requested time period, as determined by CAHIIM, the program may be assigned a Site Visit in the next academic year.
Focused Review (top)
A focused review of the program may be requested at anytime by the Board of Commissioners as a result of the APAR information submitted. The review may or may not include a site visit of the program, when concerns are raised regarding a pattern of less than expected satisfactory programmatic outcomes as determined by CAHIIM.
Probationary Accreditation (top)
This category is not applicable to initial applicant programs. Probationary Accreditation is awarded when the program is not in compliance with the Standards and the deficiencies are so serious that the capability of the program to provide an acceptable educational experience for the students appears to be threatened. Probationary Accreditation is limited to a one year period.
When the CAHIIM recommends Probationary Accreditation, the sponsoring institution’s chief executive officer is notified. The CAHIIM accreditation award letter contains a clear statement of each deficiency deemed to be in non-compliance with the Standards.
Before awarding Probationary Accreditation, the CAHIIM Board of Commissioners provides the sponsoring institution with an opportunity to respond in writing to all cited Standard deficiencies.
During a period of Probationary Accreditation, programs are recognized and listed as accredited.
CAHIIM awards of Probationary Accreditation are final and not subject to appeal.
Failure to correct the deficiencies may result in Withdrawing Accreditation. Currently enrolled students and those seeking admission should be advised that the program is on Probationary Accreditation. However, enrolled students completing the program under Probationary Accreditation are considered graduates of a CAHIIM accredited program.
Administrative Probationary Accreditation (top)
Administrative Probationary Accreditation will be awarded when a program does not comply with one of the following administrative requirements for maintaining accreditation as required by the Standards:
• Submitting the CAHIIM Annual Program Assessment Report (APAR) and other required reports by the determined CAHIIM date.
• Participating in a designated periodic site visit of the accredited program.
• Informing CAHIIM of any adverse changes in the institution affecting the program’s accreditation. Changes in program officials (Chief Executive Officer, Dean, and Program Director), within 30 days of the effective date. Please contact CAHIIM Staff with any questions.
• For Program Director changes, notification must include; date of implementation, name and credentials, a copy of the person’s current curriculum vitae, and confirmation of all contact information, phone, fax, e-mail.
• Payment of all CAHIIM administrative fees.
Administrative Probationary Accreditation may be as short as thirty (30) days, but may not exceed six months. Exceeding six months will result in a recommendation of accreditation withdrawn.
CAHIIM awards of Administrative Probationary Accreditation are not subject to appeal. During a period of Administrative Probationary Accreditation, programs are recognized and listed as being accredited.
Accreditation Withheld (top)
A program seeking Initial Accreditation may be recommended for Accreditation Withheld if the accreditation review process confirms that the program is not in compliance with the Standards. The program is provided with a clear statement of each Standard deficiency. When the CAHIIM recommends Accreditation Withheld, the chief executive officer is notified by express mail.
Prior to the final decision. the CAHIIM provides an opportunity for the institution to request CAHIIM Procedural Reconsideration of its recommendation to the program. The letter informing the CEO of the accreditation recommendation describes the Reconsideration Process. The sponsoring institution may withdraw its Application for Candidacy at any time.
Accreditation Withdrawn (top)
Accreditation may be involuntarily withdrawn from a program as a result of Administrative Probationary Accreditation or Probationary Accreditation, if, at the conclusion of the specified probationary period, the accreditation review process confirms that the program is not in compliance with the administrative requirements for maintaining accreditation or is not in compliance with the Standards. When the CAHIIM recommends Accreditation Withdrawn, the Chief Executive Officer of the sponsoring institution is notified by express mail.
Graduates enrolled in the program at the time the sponsoring institution is notified that their accreditation has been withdrawn will be considered graduates of a CAHIIM accredited program.
Prior to the final decision, the CAHIIM provides an opportunity for the institution to request CAHIIM Procedural Reconsideration of its recommendation to the program. The letter informing the CEO of the accreditation recommendation describes the Reconsideration Process. The sponsoring institution may withdraw its accreditation at any time.
The sponsoring institution may apply for accreditation as an initial applicant when the program is believed to be in compliance with the Standards and with administrative requirements for maintaining accreditation.
Appeals Procedure (top)
An institution may only appeal final decisions of withholding or withdrawing of accreditation. The CEO must initiate this process by written request to CAHIIM to request information regarding the Appeal Process and the applicable processing fee.
Evaluation of the Accreditation Process (top)
CAHIIM continuously evaluates the effectiveness of the accreditation review process for educational programs. To assist in these evaluation efforts, an Accreditation Process Evaluation form is used to solicit information on the following:
• The arrangements for the Site Visit;
• The performance of the Site Visit Team;
• The participation of institutional personnel in conducting the analytical self-evaluation and preparing the Self-Assessment Document;
• Suggestions for improving the overall program review process.
Voluntary Withdrawal of Accreditation (Closing an Accredited Program) (top)
A college or university that establishes a program incurs an obligation to the students to conduct the program as planned. If circumstances require program closure, advanced notice is required to CAHIIM. Programs may not request voluntary withdrawal of accreditation until all students have graduated. Until then, the institution must continue to pay the CAHIIM Annual Accreditation Fee.
Notification of Program withdrawal must be submitted in writing by the chief executive officer to include:
• Reasons for program closure.
• The date of the last graduating class.
Guidelines for Advertising Accreditation Status (top)
CAHIIM requires that all institutions sponsoring CAHIIM accredited programs, to follow the guidelines listed below to assure accuracy in advertising and announcing of the program’s accreditation status.
Statements should not be made about a possible future accreditation status not yet confirmed by the CAHIIM. Statements concerning accreditation should not be the focal point in an advertisement.
CAHIIM must be named as the accrediting organization.
The following statement, or similar statement, may be used in catalog announcements, descriptive or promotional information, and advertising:
The HIM/HI (degree level) program is accredited by the
Commission on Accreditation for Health Informatics
and Information Management Education (CAHIIM).
The following is an example of a statement for new programs in Candidacy Status:
The HIM/HI (degree level) program is in Candidacy Status, pending
accreditation review by the Commission on
Accreditation for Health Informatics and Information
Management Education (CAHIIM).
Please contact CAHIIM Staff with any questions regarding publishing the program’s accreditation status.
Inactive Programs (top)
The sponsoring institution may request inactive status for up to two (2) years and may not accept a new class of students. The program must continue to pay the CAHIIM Annual Accreditation Fee. After being inactive for two years and the program does not admit a new class of students, the program will be considered discontinued and accreditation may be withdrawn. The program must notify CAHIIM Staff immediately upon reactivation.
AHIMA Certification Eligibility (top)
When the program is awarded accreditation, graduates will be eligible to apply and take the national certification exam as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT). Published policies regarding exam(s) eligibility should not be included within the CAHIIM accreditation statement.
Please contact the AHIMA Certification Department at 312.233.1100 or at heather.rich@ahima.org if you have any questions or are in need of certification information or past reports for your program.
Published Lists of Accredited Programs (top)
The CAHIIM Accredited Programs Directory is the official list of accredited programs.
Substantive Change Processes (top)
CAHIIM must be notified within 30 days for the following changes:
• Institutional Structure Changes A letter must be submitted when a program has a change with the sponsoring institution, which may include a change in ownership, transfer of sponsorship, mergers, or legal status affecting program students. The program may be assigned a Focused Review and a Site Visit within one year, to review the new entity.
• Changes in Program Delivery (top)
A letter must be submitted when the complete land-base program is offered through distance delivery.
A program must notify CAHIIM when there is a change to inactivate the program (i.e., not accepting a new class of students).
• Changes in Program Officials (top)
A written letter on the institution's letterhead from the Dean informing CAHIIM Staff must be submitted with all contact information including mailing address and e-mail.
For Program Director: A current curriculum vitae must be submitted to CAHIIM Staff that documents the credentials and academic degree in respect to the Standards. Included must be the effective date of the change.
Dean or President: Submit complete contact information to CAHIIM Staff. Included must be the effective date of the change.
ASPA Member Code of Good Practice (top)
CAHIIM as a member organization follows these principles of the Association of Specialized and Professional Accreditors.
Due Process Procedures (top)
Program Complaints: Accredited programs are subject to complaints from students and other public stakeholders. CAHIIM will initiate the required process for investigating these concerns if they target non compliance issues related to the Standards. Complaints must not be anonymous and must show evidence that steps to reach a resolution at the sponsoring institution have been exhausted. Please review the steps for initiating the CAHIIM Complaint Process. Please contact CAHIIM Staff in order to discuss this process before submission.