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Health Information Management Initial Accreditation

Introduction

Prior to the application process, a sponsoring institution must develop a program that meets the professional curriculum content and quality of the program as measured by the Health Information Management (HIM) Accreditation Standards and Program administrators must ensure that the program is sustainable per its resource and needs assessment. The program must be developed to ensure stability professionally and financially.

CAS (CAHIIM Accreditation System) is the online system for Comprehensive Accreditation Review for Initial Accreditation applicants.

Timeline

HIM initial-accreditation-timeline

Candidacy Status Application Process

Conditions for Pre-Application

Timing: Program assesses readiness for application for accreditation. A program must not apply until 6 months before the date of the first graduation class.

The following requirements must be met or completed during this stage in development and when submitting an application:

Program Director: Have hired a permanent Program Director that meets the minimum qualifications in the Standards for a Program Director. The position must be full time throughout the application process.

Full-Time Faculty Member: This individual must report to the qualified Program Director.

Applicant Program Campus: The program and campus applying for accreditation must award the degree which includes online applicant campuses.

Other campus institutional requirements: The sponsoring institution is accredited by a regional or national accrediting institutional organization recognized by the U.S. Department of Education (USDE) to offer a degree or the sponsoring institution accredited by a national accreditor with USDE provisions their Grant for Accreditation for establishing eligibility to participate in Title IV programs. Upon request, the applying campus program must provide the OPEID number assigned by the U.S. Department of Education as proof of participation for financial aid. State Board of Education approvals must also be completed.

Step 1:  Letter of Intent

Programs that meet the minimum requirements for application must submit a Letter of Intent that describes
the readiness to pursue Initial Accreditation from the President/chief executive officer. Submit the letter to CAHIIM staff at george.payan@cahiim.org.

Content Description:

1. Describe support for the program.

2. State reasons for the program inception or program need.

3. Confirm state and institutional authority to provide the degree granting program.

4. Indicate the month and year of the program launch.

5. Indicate projected month and year of first graduation class.

Step 2: Application in the CAHIIM Accreditation System

Complete the Registration and Profile.

If the pre-application conditions have been met the program may initiate this step of completing a Program Profile. All program and institutional information fields must be completed accurately and reflect the program offered.

Upload all "Supporting Materials" in the online system. The following files must be completed and submitted. The CAHIIM templates must be used.

1. Synopsis of Curriculum: List all required courses in the curriculum (general education and the
professional courses) for each specific quarter/trimester/semester within the total curriculum sequence.

2. A Sample Syllabus for a core Health Information Management course from the final phase of the program.

3. Curriculum Requirements:  Complete and upload the CAHIIM Competencies Report. Ensure program courses are mapped to the curriculum content.

4. Curriculum Vitae for the Program Director - Current employment must be up to date.

5. Curriculum Vitae for the Full-Time Faculty Member Must be teaching in the program. Current employment must be up to date.

Submit the Application

Once all documents are uploaded in the system and all required fields completed, the program's application is submitted in the "Actions Tab". A program applicant's registration that is not complete and the application documents not submitted will be automatically and permanently deleted within 30 days.

Step 3: Submit Pre-Application Fee

Once the above stages are completed, the Application Fee of $500  must be submitted. The fee must be received before the assessment process may begin on a submitted application in the system.

Step 4: Staff Review of Application

The application will be reviewed upon receipt of all application requirements. An assessment will be provided within 90 days.

CAHIIM senior staff reserves the right to make final administrative decisions of a program's application status with CAHIIM.

Step 5: Program Response

A response in the system is required that provides any clarification or request for information.

Candidacy Status Decision and Description 

Denied: An application may be rejected if it does not meet the conditions for application or there are documented issues of non compliance with the Standards at anytime.

Accepted: Accepted into CAHIIM Candidacy Status.

CAHIIM Candidacy Status Description - An application stage while the Candidate program is allowed to complete the Self Assessment information and documentation in the online system.

An applicant program allowed into Candidacy Status is:

1. assigned a CAHIIM Educational Program Code (EPC)

2. assigned a Self Assessment Due Date (1 year from date of when Candidacy Status was achieved)

3. assigned a Candidacy Status expiration date (2 years from date of when Candidacy Status was achieved)

4. Sent Invoice for the Candidacy Status Fee

Expiration of Candidacy Status

This status will be terminated if it is found that the Requirements for Candidacy have not been maintained at any time or the maximum 2-year period has elapsed. If the program has been informed of this action, the program must reapply by submitting a new Application for Candidacy.

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

Required Forms for completion and file uploads in this stage:

1. Program Evaluation Plan (required template for Standard #4. Program Goals)
2. Budget Template (required template for Standard #22. Financial Support)
3. Synopsis of Curriculum (required template for Standard #24. The Curriculum)
4. Curriculum Requirements (required for Standard #24. The Curriculum) Complete the applicable template mapping program courses to required curriculum content.
5. Learning Management System (required template for Standard #24 The Curriculum)
6. CAHIIM Help for Program Users (CAS Instruction Manual)  

Online Content Delivery

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

Helpful Tips:

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

CAHIIM Review

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

Site Visit

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

The program is invoiced the Site Visit Processing Fee in this stage.

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

Program Response

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

Council and Board Review

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

Progress Report Requirement

In order to maintain accreditation status the program must submit a progress report that satisfies the remaining Standard deficiencies that resulted from the review process. The Board Report will reflect the current Not Met or Partial Met Standard deficiencies that require the institution’s attention and provides guidelines for resolution and evidence of implementation in order to achieve full compliance for the program.

Progress Report Deficiency Validation Tool template: This format must be used for completing partial met and not met curricula considerations for Standard 24.

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

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

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

 

 

Situations that Adversely Affect the Application Process 

Change in Program Director: A change in program director is prohibited during the application process and will lead to removal of Candidate Status and application rejected if the Self Assessment stage has already been submitted in the CAHIIM Accreditation System.
 
A stable program with no deficiencies may appoint a new permanent program director that is a full time faculty person that meets the qualifications of Program Director in the Standards. The new program director candidate must have been employed and have had involvement in the program for a minimum of 12 months.