CHAP Standards of Excellence

The CHAP accreditation process utilizes the CHAP Standards of Excellence that are driven by considerations of management, quality, client outcomes, adequate resources, and long term viability.

The goal is to assist all types of community-based health care organizations to:

  • Strengthen internal operations
  • Promote continuous quality improvement techniques and systems
  • Promote consumer safety, satisfaction and outcomes 
  • Affirm public trust 
  • Meet community health needs in a cost efficient and effective manner
  • Maintain the viability of community health practice nationwide

In keeping with its mission to define and advance the highest standards of community based health care, CHAP continually reviews the Standards of Excellence to assure currency and relevance for the community health care industry. Revisions are created through a multi-customer input mechanism utilizing industry experts, providers, and professional staff, and implemented thoughtfully after a published comment period. 

CHAP standards place a strong emphasis on organizational management and client outcomes.  Use them as a blueprint to build and maintain a highly effective community based care organization, assuring positive outcomes for the community served and the viability of the organization.

CORE Standards of Excellence

The CORE Standards of Excellence address the scope and complexity of community-based health care providers in today’s health care environment and are fundamental to the quality, safety, appropriateness, and effectiveness of all services and programs accredited by CHAP.  The CORE standards are designed as a companion to the service specific Standards of Excellence. For single service organizations, compliance with certain CORE standards will also ensure compliance with a related standard in the service specific area. For larger, more complex or multi-service line organizations, the companion standards will facilitate detailed planning and oversight at the service line level, while CORE can serve as an integrating mechanism for the entire organization. 

Core Standards:

  • are to be used in conjunction with service specific standards
  • ensure compliance with Federal, state and local regulatory requirements, and regulatory requirements that address the health and safety of employees and clients
  • address broad concepts of quality in community based care, and are relevant and required for all organizations seeking CHAP accreditation
  • compliance can be determined with a one day on site review BEFORE a license granting patient service rights has been granted where states require accreditation prior to licensure.  This provides TEMPORARY accreditation which allows license to be issued and patients to be served to meet initial census/service requirements needed for a full accreditation site visit
  • incorporate, where required, CMS requirements for home health, hospice and DMEPOS Providers

Service Specific Standards:

  • address requirements additional to Core which are unique to the specific service or business line
  • incorporate, where required, CMS requirements for home health, hospice and DMEPOS Providers

All CHAP Standards of Excellence are built upon four underlying principles, which serve as the sections of the standard manuals. These principles are Structure and Function, Quality of Services and Products, Availability of Human, Financial and Physical Resources, and Long Term Viability. The following describes more about the content in each section.   

I.     The Organization’s Structure And Function Consistently Supports Its Consumer Oriented Mission

A. Statement of Mission

B. Organizational Structure And Functional Mechanisms

C. Organizational Relationships/Chart

D. Administrative Authority and Responsibility

E. Organizational Policies

F. Communication and Information to Consumers

G. Ethical Issues

H. Research Initiatives

II.    The Organization Consistently Provides High Quality Services And Products.

A.    Business and Clinical Practices

B.    Client Access to Care, Services and Products

C.    Emergency Planning

D.    Coordination of Operations  

E.    Client Records

F.    Performance Improvement

G.    Safety of Employees and Clients

H.    Complaints

III.     The Organization Has Adequate Human, Financial, And Physical Resources To Accomplish Its Stated Mission And Purpose.

A.    Human Resources

B.    Contracts

C.    Financial Management

D.    Financial Information System

E.    Physical Facilities

F.    Management Information System

IV. The Organization Is Positioned For Long Term Viability.

A.    Strategic Planning

B.    Annual Evaluation of the Organization

Each standard statement may be comprised of four (4) parts to further specify requirements:   

    1. Standard statement - A blueprint for success that recognizes excellence
    2. Criterion - A statement that defines in detail the requirements of the standard
    3. Element - A component of each criterion that delineates requirements
    4. Sub-element – Additional statements that provide more definition of selected elements.

Evidence Guidelines

Standards are formatted with relevant Evidence Guidelines. The evidence guidelines are not standards or criteria. They are intended to provide examples to the organization and to the CHAP Site Visitor. The examples may be used to determine organizational compliance with the standards. The Site Visitor will clarify, verify and quantify data to substantiate findings. The letter preceding each evidence guideline indicates the source of the information to be used by the Site Visitor in the accreditation process. Sources of evidence are:

D:   Documentation
I:    Interview
O:   Observation
S:    Surveys



Frequently Cited Standards

Click here to view the trends of the most frequently cited required actions (Standards) from 2011.

Click here to view the trends of the most frequently cited required actions (Standards) from 2009-2012.

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