Guidelines For Accreditation Decisions

Initial and Reaccreditation Decisions

The Massachusetts Medical Society makes a decision regarding the provider's accreditation status based on the accumulated compliance findings for each Accreditation Requirement. This decision could be one of five options:

  1. Provisional Accreditation,
  2. Accreditation,
  3. Accreditation with Commendation,
  4. Probation, or
  5. Non-Accreditation.

1. Provisional Accreditation: Provisional Accreditation is the standard status for initial, or first-time, applicants, and is associated with a two year term. To achieve Provisional Accreditation, the applicant must be found in Compliance in all Level 1 Requirements Criteria 1-3, 7-12. The MMS may grant "Extended Provisional" accreditation to an already Provisionally Accredited provider one time, for up to two years. Provisional Accreditation may also be granted when an accredited organization's CME program is so altered that it is essentially a new program.

2. Accreditation:  Accreditation is the standard status for reaccreditation applicants, and is associated with a four year term. Providers will be reviewed for compliance with Level 2 requirements Criteria 1 - 13.  For accredited providers seeking Accreditation, Non-Compliance with any Accreditation Requirement will necessitate a Progress Report and/or focused or full survey. Failure to demonstrate compliance in the Progress Report and/or focused or full survey may result in Probation.

3. Accreditation with Commendation: Accreditation with Commendation is associated with a six-year term, and is available only to reaccreditation applicants. A reaccreditation applicant is considered for Accreditation with Commendation if the applicant meets the criteria for Accreditation with Commendation: Compliance with Criteria 1 – 22.

To be eligible for a change in status, a provider must have been found compliant with Accreditation Criteria 1-13, and must have no more than one noncompliant finding for Criteria 16-22.  If the provider submits a Progress Report that is accepted, the provider is eligible for a change in status to Accreditation with Commendation.  This requirement applies to accreditation decisions made after January 19, 2011.

4. Probation: An accredited program that seriously deviates from Compliance with the Accreditation Requirements may be placed on Probation. Probation may also result from a provider's failure to demonstrate Compliance in a Progress Report.

Providers who receive Probation at reaccreditation receive the standard four-year term of accreditation for two years, maximum. Accreditation status, and the ability for a provider to complete its four-year term, will resume when a Progress Report is received, validated, and accepted by the MMS.

Probation may not be extended. Therefore, providers on Probation that fail to demonstrate Compliance with all MMS Requirements within two years will receive Non-Accreditation.

Note that Provisionally Accredited providers cannot be put on Probation. Rather, Provisionally Accredited providers that seriously deviate from Compliance will receive Non-Accreditation.

5. Non-Accreditation: Although decisions of Non-Accreditation are rare, MMS reserves the right to deliver such decisions under any of the following circumstances:

  • After the initial survey. To achieve Provisional Accreditation, first-time applicants must be found in Compliance in all Level 1 Accreditation Requirements. Initial applicants who receive Non-Accreditation may not be reviewed again by the MMS until one year from the date of the MMS meeting at which the decision was made
  • After Provisional Accreditation. Provisionally accredited providers that seriously deviate from Compliance will receive Non-Accreditation. These providers are not eligible for Probation.
  • After a Progress Report. For accredited providers on Probation, Non-Compliance with any one of the Criteria will be cause for Non-Accreditation.

Non-Accreditation decisions will be effective immediately, unless the MMS Committee on Accreditation Review specifies otherwise. MMS will confirm in writing the specific date on which the provider’s accreditation will end. A provider who receives Non-Accreditation is responsible for payment of all fees and submission of all required reports until the effective date of Non-Accreditation. Failure to do so will result in immediate Non-Accreditation. The MMS waives the requirement of a Pre-application for the provider that chooses to submit an Initial Self Study Report during the one-year time period prior to the effective date of Non-Accreditation. The process and standards for review of newly Non-Accredited applicants are the same as for all other applicants.

Progress Report Decisions

Some providers are required to submit Progress Reports to MMS. A decision regarding a provider's Progress Report could be one of three options.

  1. Accept: MMS accepts a Progress Report when the provider has furnished evidence of Compliance with the Accreditation Criteria that were in Non-Compliance. A provider's demonstration of Compliance in all Criteria 1-13 will result in its ability to complete its four-year term with a status of Accreditation. Providers who are found in compliance with Criteria 1-13, and all but one of Criteria 16-22, may have their accreditation status changed to Accreditation with Commendation and their term extended by two years (for no more than a total of six years from the original accreditation decision), once they have demonstrated Compliance through a Progress Report with the Criterion that was previously in Non-Compliance.
  2. Clarification Required: If the Progress Report requires clarification, the provider has corrected most of the Criteria that were in Non-Compliance, but some additional information is required to be certain the provider is in Compliance. An additional Progress Report may be required.
  3. Reject: The MMS rejects a Progress Report if it does not provide evidence that the areas of Non-Compliance have been corrected. Either a second Progress Report or a focused accreditation survey may be required. The MMS can place a provider on Probation or Non-Accreditation as the result of findings on a Progress Report.
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