The Health Resources and Services Administration
(HRSA) currently contracts with The Joint
Commission to provide Health Center [1]
Program grantees with initial and resurvey
accreditation evaluations. HRSA encourages
health centers to pursue accreditation
from an independent accrediting body as
accreditation status continues to be viewed
as a benchmark of quality.
In the past, health centers have sought
external accreditation by three methods:
- The Joint Commission accreditation
with HRSA payment of certain costs for
accreditation services;
- The Joint Commission accreditation
as part of the survey of an affiliated
hospital without HRSA financial support;
and
- Accreditation through another ambulatory
care accrediting organization, without
HRSA financial support.
This Policy Information Notice (PIN)
outlines the Accreditation Initiative
offered by HRSA to support certain accreditation
costs for health centers through its contract
with The Joint Commission. HRSA recommends
that all health center administrators
discuss their accreditation-related plans
with their project officers on an annual
basis. Additional information specific
to the HRSA-funded Accreditation Initiative
can be found at jointcommission.org
(Not a U.S. Government Web site).
Per a competitive process, HRSA has
contracted with The Joint Commission to
provide 35 initial surveys and 100 resurvey
evaluations for Health Center Program
grantees during contract year 2007 (April
1, 2007 – March 31, 2008). For health
centers undergoing initial accreditation
or resurvey during contract year 2007,
HRSA will pay the annual fee and on-site
survey cost for the ambulatory care survey
and concurrent laboratory surveys. In
addition, HRSA will pay survey fees if
a health center requires an extension
survey as a result of expansion of its
clinical services. HRSA will not pay for
extension surveys requested under other
circumstances for the convenience of the
health center.
Due to the Joint Commission’s policy
of accrediting organizations as a whole,
health centers also providing home health
care, long-term care, certain types or
volume of behavioral health services,
and/or moderate or high complexity laboratory
services will be required to have those
services surveyed at the time of their
ambulatory care survey. Currently, the
contract includes HRSA funding for behavioral
health services surveys [except for the
Substance Abuse & Mental Health Services
Administration (SAMHSA) supported opioid
treatment programs] and laboratory services
when they are concurrent with the ambulatory
care survey. Health centers must pay for
all other applicable Joint Commission
survey fees (e.g., home care, long-term
care, conditional follow-up surveys).
In addition, Health centers must pay for
Clinical Laboratory Improvement Amendments
(CLIA) mandated biennial surveys and annual
fees for moderate or high complexity medical
laboratories when they do not coincide
with a HRSA-supported Joint Commission
ambulatory care survey. For those health
centers providing on-site behavioral health
services and which are surveyed during
the 2007 contract year, HRSA will fund
the annual fee and the on-site survey
fee.
Since the inception of HRSA’s Office
of Performance Review (OPR), it has been
HRSA’s policy not to conduct the
OPR review in the same calendar year as
the Joint Commission accreditation survey,
as doing so may unnecessarily burden health
centers. It is HRSA’s intent to
coordinate the Joint Commission surveys
and OPR reviews so that they do not occur
in the same calendar year.
A. Health Center Initial Accreditation
Surveys During Contract Year 2007:
Organizations interested in HRSA support
for initial accreditation under the Accreditation
Initiative during the contract year 2007
should forward an application/letter of
interest (LOI) directly to the Accreditation
Initiative Program. The LOI shall contain
the following, in narrative format (not
to exceed two pages):
- Name and address of health center
including the UDS number of the section
330 grant recipient (and name of section
330 grant recipient, if different).
- Name of HRSA Project Officer.
- Name, telephone, fax numbers, mailing
address, and e-mail address of the health
center’s Chief Executive Officer.
- Name, telephone, fax numbers, mailing
address, and e-mail address of the health
center’s lead person for the Joint
Commission accreditation process.
- A brief description of the health
center. Please include information on
funding sources (i.e., Community Health
Center (CHC), Migrant Health Center
(MHC), Health Care for the Homeless
(HCH), Public Housing Primary Care (PHPC)),
the number of health care delivery and
administrative sites, patient population,
and the number of patient visits per
year.
- The health center’s reasons
for pursuing accreditation.
- If the health center has been previously
accredited, please provide dates of
past accreditation survey(s) and the
name(s) of the accrediting organization(s).
- A concise, yet thorough description
of the extent to which the health center
has addressed the following indicators
of readiness for accreditation (a
health center will not be disqualified
if all indicators have not been met):
a. The health center has factored into
its planning process a minimum of 6
months preparation time for the accreditation
survey;
b. The health center has designated
a lead person responsible for accreditation
preparation;
c. The health center has performed a
self-assessment comparing The Joint
Commission’s standards against
the health center’s internal processes
and practices.
- The health center’s preferred
month for undergoing the Joint Commission’s
on-site survey (Note: the recommended
time for preparation for a survey is
at least 6 months).
- Any additional information that indicates
readiness for accreditation.
Please be sure to submit all of the requested
information. Failure to do so can render
the LOI incomplete and it may not be considered
until the missing information is provided.
The LOI should be submitted electronically
to the Accreditation Initiative Program
at:
Accreditation Initiative Program
accreditationinitiative@hrsa.gov
301-594-0818
LOIs will be considered on a first-come-first-served
basis using the following criteria to
determine which health centers are approved
to participate in the Accreditation Initiative:
- Complete LOI;
- Health center’s Project Officer
recommendation; and
- Fiscal soundness.
HRSA will notify each health center of
its approval status by email within a
minimal time of receipt of the LOI. Final
approval for participation is at the discretion
of HRSA. Organizations approved by HRSA
for the Joint Commission initial accreditation
in contract year 2007, will be contacted
by The Joint Commission (see below).
B. Accreditation Expectations:
As accreditation serves to support health
center quality and promote quality improvement,
during the accreditation period, health
centers are encouraged to uphold and enhance
their quality activities through continued
evaluation and development of key systems
and processes, as well as, incorporate
the standards requirements into day-to-day
activities.
Also, to facilitate continuous compliance
with standards, The Joint Commission requires
accredited organizations to conduct compliance
reporting through the Periodic Performance
Review.
C. Health Center Re-Accreditation
Surveys in 2007:
Eligible health centers may preserve their
accreditation status through re-accreditation.
Organizations eligible for re-accreditation
during contract year 2007 under the HRSA
Accreditation Initiative will be contacted
directly by The Joint Commission to coordinate
their re-accreditation survey. Health
centers seeking re-accreditation are not
required to submit a LOI and supporting
documentation to the Accreditation Initiative
Program.
D. Statewide Accreditation Initiative:
Primary Care Associations (PCAs) can play
an important role in the accreditation
process by providing encouragement and
coordination to health centers in their
State. In order to provide a vehicle for
the PCA to interact with their health
centers, HRSA has developed the Statewide
Accreditation Initiative. In this project,
the sponsoring PCA is responsible for
collecting all of the LOIs from the participating
section 330 health centers (representing
all health centers within their State
who desire to participate) and forwarding
them in a single batch to the Accreditation
Initiative Program. A transmittal letter
shall include:
- An indication of the PCA Board’s
formal commitment to a statewide/regional
Accreditation Initiative;
- The identification of a person responsible
for leading statewide accreditation
activities; and
- A brief description of the support
the PCA will provide to sponsored health
centers (i.e., training, technical assistance,
mock surveys).
PCAs are also eligible to request educational
and technical assistance resources for
their health centers by contacting the
Accreditation Initiative Program.
After a health center is approved for
initial survey, The Joint Commission will
send further information on the accreditation
process, including:
- The full Comprehensive Accreditation
Manual for Ambulatory Care;
- Access to the health center’s
dedicated extranet site on the Joint
Commission’s Web site;
- The Application for Accreditation
process including the opportunity to
indicate a preferred month of survey;
- How to achieve compliance with standards
and prepare for your survey; and
- Other helpful information.
Under the HRSA contract, The Joint Commission
provides continuous access to technical
assistance, including several modes of
educational training for survey preparation.
Health centers and PCAs should contact
the Accreditation Initiative Program for
further details.
HRSA would like to ensure that Project
Officers and other staff have an accurate
listing of all health centers holding
external accreditation status. Therefore,
if your health center currently holds
an external accreditation with any organization
other than The Joint Commission, please
provide the following information to the
HRSA Accreditation Initiative Program
at accreditationinitiative@hrsa.gov:
- Health center name, city, and State;
- Health center’s accreditation
contact name, e-mail, and phone number;
- Date of first accreditation and accreditation
organization name; and
- Date of most recent accreditation
and accreditation organization name.
Additional information regarding the
Joint Commission application process can
be found at http://www.jointcommission.org.
Questions and comments pertaining to this
PIN should be referred to the Accreditation
Initiative Program at accreditationinitiative@hrsa.gov,
or (301) 594-0818.
___
[1] Here and
throughout this PIN, “health center”
refers to organizations receiving a grant
under the Health Center Program authorized
in section 330 of the Public Health Service
Act.
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