A bespoke build is an engagement in which IHS drafts documents and program content for your organization. It runs through six phases: a gap assessment, questionnaires, document and evidence mapping, drafting, mock review, and readiness support. Your organization supplies the facts, approves and adopts the result, and submits it. The scope you agree on sets which phases apply.
Last reviewed: October 2026.
What are the phases of a bespoke build?
- Gap assessment. A series of calls walks everyone involved through each standard, and IHS compares what you have against the governing text.
- Questionnaires. IHS sends questions that collect your operating facts.
- Document and evidence mapping. IHS builds a crosswalk from each requirement to the policy, form, log or record that answers it.
- Drafting. IHS drafts policies, procedures, forms and program content for your organization, with approval lines for your reviewers and open slots where only you can supply the answer.
- Mock review. IHS reviews the result against the governing text. Depending on scope, that is a Mock Desktop Review of your documents, a Mock Validation Review of whether practice matches policy, or both.
- Readiness support. IHS drafts the application or survey packet text, drafts correspondence, and drafts responses to findings. Your organization files and sends them.
Some engagements are narrower, and the written scope says which phases apply.
From Tom's experience
I run a gap analysis as an orienting process: a series of calls that walk through every standard, covering what each requires operationally and what documentation you will have to submit. The point is that everyone who will be involved knows all of the requirements.
Thomas G. Goddard, JD, PhD, founder of IHS and former Chief Operating Officer and General Counsel of URAC.
Who does what?
| Task | IHS | Your organization |
|---|---|---|
| Gap assessment and orientation calls | Leads the calls and records the findings | Brings the people who run each area |
| Questionnaires | Writes and sends them | Answers them |
| Policies, procedures, forms and program content | Drafts them | Reviews, changes and approves them; clinical content is approved by your licensed clinicians |
| Adopting and running the program | Not IHS's role | Adopts it and runs it |
| Applications, correspondence and responses to findings | Drafts the text | Files it and sends it, under your organization's name, through your named contact |
| The accreditation or certification decision | Has no part in it | Receives the decision |
On NCQA work, Maureen Plumstead leads accreditation and recognition, and Thomas G. Goddard, JD, PhD leads program development.
What does IHS not do?
- IHS does not contact, call, email, or submit to an accreditor or regulator for you. IHS drafts the text; your named contact sends it.
- IHS does not grant, influence or promise an accreditation or certification decision. The accreditor or regulator makes the decision.
- IHS is a consulting firm. Nothing it writes is legal advice; your counsel decides questions of legal interpretation.
- IHS does not run your operations or configure your systems.
- IHS does not publish its fees. Each engagement is scoped after the introductory meeting.
What do IHS's process terms mean?
- Standard-by-Standard Review
- An educational series of calls that walks the people involved through each standard, so they learn what it asks for and what you must be able to show.
- Mock Desktop Review
- IHS reads the documents you plan to submit against the governing text, as a reviewer reading them would.
- Mock Validation Review
- IHS tests whether your staff's practice matches what your policies say, as a validation reviewer would.
- Starfinch
- The software IHS uses to hold standards, documents and citations together.
How do I start?
Every engagement begins with an introductory meeting with Thomas G. Goddard, JD, PhD, where you describe your situation. The button below books it.