What You Need to Know About Validation Surveys and Disparity Rates

CMS Validation Surveys play a pivotal role in maintaining the integrity of accreditation organizations (AOs) and ensuring compliance with federal standards. The purpose of validation surveys is to assess the AO’s ability to ensure compliance with Medicare conditions.

CMS has contracted with two national organizations to conduct validation surveys, sending their surveyor(s) to directly observe the AO surveyor(s). The new approach is designed to prevent the need for a separate survey of the health care organization, and to focus on evaluating The Joint Commission’s ability to assess compliance with the Conditions of Participation.

It's crucial to clarify that the disparity rate is not a measure of how closely an AO's standards align with CMS regulations. Instead, it specifically addresses variations in condition-level deficiencies identified during the validation process.

There are, however, limitations when discussing disparity rates. The disparity rate does not solely measure the AO’s performance. Additionally, a high AO disparity rate does not necessarily indicate unsatisfactory performance by the AO. AO program types having smaller sample sizes may result in higher AO disparity rates.

Understanding these metrics is essential for continuous improvement. By recognizing and addressing disparities, AOs can collaboratively work with CMS to enhance the consistency and quality of healthcare services. Embracing these metrics presents an opportunity to foster an environment of shared learning and improvement. Collaboration with CMS becomes a catalyst for positive change, ensuring a healthcare landscape marked by excellence.

Historically, state agencies conducted “look back” validation surveys within 60 calendar days following AO surveys. Moving forward, CMS contracted with two national organizations to conduct validation surveys, sending their surveyor(s) to directly observe the AO’s surveyor(s). The new approach is designed to prevent the need for a separate survey of the health care organization, and to focus on evaluating the AO’s ability to assess compliance with the Conditions of Participation. CMS expects to do fewer of these direct observation validation surveys compared to the "look back" validation surveys.

The national contracted organizations will send the same number of surveyors as the AO’s survey team to ensure that each surveyor is observed throughout the triennial deemed survey. The CMS–contracted surveyors will not conduct a separate survey or issue a CMS 2567 survey report. All survey findings will be identified by the AO’s survey team and captured in the survey report, and health care organizations will respond to the AO for any identified findings.

CMS has announced the resumption of validation surveys in 2024. For detailed information about accrediting organizations' disparity rates and survey data, we encourage you to visit the CMS.gov website.

Understanding and harnessing the significance of CMS Disparity Rates within Joint Commission accreditation is a strategic step towards fostering a healthcare environment marked by continuous improvement, transparency, and unparalleled patient care.