Purpose
This Program Assistance Letter (PAL) amends
Program Information Notice 2007-17 (PIN 2007-17).
This PAL confirms that the processes and requirements
for applying for initial accreditation remain
consistent with the guidance described in PIN
2007-17 and offers guidance on new and expanded
opportunities for training and survey services
for organizations funded under the Health Center
Program (section 330 of the Public Health Service
Act). This PAL contains instructions for health
centers to apply for technical assistance, training,
mock surveys, and survey services under the
current contract with The Joint Commission (TJC).
Introduction
The Accreditation Initiative services for eligible
Health Center Program grantees were initially
established by the Health Resources and Services
Administration (HRSA) through a contract with
TJC, formerly known as the Joint Commission
on Accreditation of Healthcare Organizations.
The current three-year contract with TJC provides
for survey services for ambulatory care, behavioral
health care, limited laboratory services, and
technical assistance and training for health
centers. Eligible entities under the Accreditation
Initiative ("health centers") are
organizations receiving funding under the Health
Center Program (Migrant Health Centers, Community
Health Centers, Health Care for the Homeless
Centers, and Public Housing Primary Care Centers).
To help encourage health centers to become
accredited, HRSA has increased both survey services,
and technical assistance and training offered
to health centers under the Accreditation Initiative
for the current contract year (April 1, 2008
– March 31, 2009).
INFORMATION/APPLICATION PROCESS FOR INITIAL
SURVEYS
Application for Initial
Services
The Accreditation Initiative is continuing
to accept applications and it is still possible
for health centers that are not currently accredited
to apply for initial accreditation. Organizations
interested in HRSA support for initial accreditation
under the Accreditation Initiative during the
contract year should forward an application/letter
of interest (LOI) directly to the Accreditation
Initiative Program accreditationinitiative@hrsa.gov.
For further instructions on how to apply for
initial accreditation please review PIN 2007-17
located on the HRSA website at: http://bphc.hrsa.gov/policy/pin0717.htm.
Mock Surveys
Through TJC’s affiliate, Joint Commission Resources
(JCR), one day mock surveys will be provided
to HRSA grantees to assist in their preparation
for their initial Accreditation Survey.
Requests for a mock survey should be submitted
by letter/email to JCR at ConsultingServices@jcrinc.com,
indicating that the request is part of the HRSA
Accreditation Initiative, and including a short
description of the reason(s) for requesting
this assistance and the month they would like
to have the mock survey.
Materials from The
Joint Commission to Support Initial Survey
After a health center is approved by HRSA for
their initial survey, TJC will send further
information on the accreditation process to
the grantee, including:
- The most current Comprehensive Accreditation
Manual for Ambulatory Care;
- Access to the health center’s dedicated
extranet site on TJC’s web site;
- Details regarding the Application for Accreditation
process; and
- Instructions on how to achieve compliance
with standards and prepare for your survey.
ADDITIONAL SERVICES FOR ACCREDITED HEALTH
CENTERS
A. Health Center
Re-Accreditation Surveys
Organizations eligible for resurvey during
the contract year under the HRSA Accreditation
Initiative will be contacted directly by TJC
to coordinate their re-accreditation survey.
TJC will continue its policy of conducting unannounced
resurveys in an attempt to ensure that health
centers are prepared for the next patient not
the next survey and will maximize the number
of resurveys conducted during this contract
period to prevent lapses in accreditation status.
B. Laboratory Services
Fees And Survey Cost
HRSA will pay TJC’s annual fees for accredited
laboratory services during the current contract
year. In addition, HRSA will pay the on-site
survey costs for TJC laboratory surveys conducted
from September 2008 through March 2009, to include
the off cycle surveys.
MATERIALS AND PUBLICATIONS
TJC will provide each HRSA Accreditation Initiative
health center participant with the following
two publications in order to inform grantees
about the new tracer methodology survey technique
and to help in performance measurement: “Applied
Tracer Methodology: Tips and Strategies for
Continuous Systems Improvement,” and “Tools
for Performance Measurement in Healthcare: A
Quick Reference Guide.”
TRAINING AND EDUCATIONAL RESOURCES
TJC will provide HRSA grantees access to participate
in the following technical assistance and educational
training opportunities related to survey preparation
and compliance with standards.
Sponsored educational
and training sessions
TJC will conduct educational and training sessions
lasting three hours or less, to be held in conjunction
with the logistical sponsorship of another organization
(e.g., health center, primary care association,
regional or national organization representing
health centers, clinical network) similar to
the process used for the annual Uniform Data
System trainings. These training sessions will
be conducted by a TJC representative and
may be tailored to the requester’s specific
area of interest. The TJC honorarium fee is
paid by HRSA and the sponsoring organization
is responsible for the costs related to the
travel and per diem of the TJC representative.
To request a training session, an organization
should contact the Joint Commission Project
Director at (630) 792-5011 for approval for
this training.
Breakfast Briefing
Audio Webinars on the Ambulatory Care Standards
The TJC affiliate, JCR, will provide HRSA grantees
with a 9 part series of training teleconferences
that focus on ambulatory care accreditation
standards, key changes and revisions to the
contract, the new National Patient Safety Goals,
as well as strategies for maintaining continuous
compliance. This audio/web-based “Breakfast
Briefing Series” will consist of a one-hour
presentation with accompanying slides. Grantees
will also be able to download each session for
a “listen on demand” format for any missed sessions.
Requests to participate in and download playback
information for the Breakfast Briefing Series
should be made by contacting the Joint Commission
Project Director at (630) 792-5011.
Customized Group
Teleconferences
The Joint Commission Project Director is available
to conduct up to 4 teleconferences with an individual
health center or groups of health centers leadership,
clinical staff, or board members regarding the
benefits, obstacles, resources, and preparation
steps relating to accreditation. Requests to
schedule a customized group teleconference should
be made by contacting the Joint Commission Project
Director at (630) 792-5011
Performance Improvement
Technical Assistance
TJC and HRSA will provide technical assistance
around “how to avoid pitfalls and common findings
during a survey,” and has established a monthly
teleconference series for HRSA grantees beginning
in September 2008 through March 2009. Each session
will have an extensive time period allocated for
questions and answers. Also, each session will
be recorded with an opportunity for HRSA grantees
to access a replay. The call schedule, dialing,
and replay information will be posted on the HRSA
website at: http://bphc.hrsa.gov.
CONTACTS
Additional information regarding the application
process for TJC can be found at (http://www.jointcommission.org).
Questions and comments pertaining to this PAL
should be referred to the Accreditation Initiative
Program at accreditationinitiative@hrsa.gov,
or (301) 594-0818.
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