BACKGROUND

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:

1. The Joint Commission accreditation with HRSA payment of certain costs for accreditation services;
2. The Joint Commission accreditation as part of the survey of an affiliated hospital without HRSA financial support; and
3. 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).

ACCREDITATION PROCESS

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):

1. 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).
2. Name of HRSA Project Officer.
3. Name, telephone, fax numbers, mailing address, and e-mail address of the health center’s Chief Executive Officer.
4. Name, telephone, fax numbers, mailing address, and e-mail address of the health center’s lead person for the Joint Commission accreditation process.
5. 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.
6. The health center’s reasons for pursuing accreditation.
7. 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).
8. 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.
9. 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).
10. 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:

1. Complete LOI;
2. Health center’s Project Officer recommendation; and
3. 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:

1. An indication of the PCA Board’s formal commitment to a statewide/regional Accreditation Initiative;
2. The identification of a person responsible for leading statewide accreditation activities; and
3. 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.

MATERIALS, TRAINING, AND EDUCATIONAL RESOURCES

After a health center is approved for initial survey, The Joint Commission will send further information on the accreditation process, including:

1. The full Comprehensive Accreditation Manual for Ambulatory Care;
2. Access to the health center’s dedicated extranet site on the Joint Commission’s Web site;
3. The Application for Accreditation process including the opportunity to indicate a preferred month of survey;
4. How to achieve compliance with standards and prepare for your survey; and
5. 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.

ADDITIONAL INFORMATION

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:

1. Health center name, city, and State;
2. Health center’s accreditation contact name, e-mail, and phone number;
3. Date of first accreditation and accreditation organization name; and
4. 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.