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H H S Department of Health and Human Services
Health Resources and Services Administration
Primary Care: The Health Center Program

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Health Center Accreditation

BACKGROUND
The Accreditation Initiative is a continuing HRSA/BPHC activity that provides survey services of ambulatory care, behavioral health, laboratory services, and technical assistance and training for health centers.  Participation is voluntary and provides an opportunity for health centers to achieve accreditation through a nationally recognized accrediting body such as the Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC), formerly known as the Joint Commission on Accreditation of Healthcare Organization.  As of January 1, 2012, 281 of the 1,128 Federally supported health centers are accredited with support from the HRSA/BPHC Accreditation Initiative

PURPOSE
The purpose of the Accreditation Initiative is to encourage and support health centers to undergo rigorous and comprehensive survey processes and achieve national benchmarks that demonstrate the highest standards of health care quality.  The Accreditation Initiative reflects HRSA’s commitment to the survey process for health centers in order to maintain and/or enhance health care quality for vulnerable populations and underserved communities. 

ELIGIBLE ORGANIZATIONS
Entities eligible to receive survey accreditation services under the Accreditation Initiative (“health centers”) are organizations receiving funding under the Health Center Program authorized in section 330 of the Public Health Service Act (42 U.S.C. 254b), as amended, specifically:

  • Community Health Center (CHC) Programs, funded under section 330(e);
  • Migrant Health Center (MHC) Programs, funded under section 330(g);
  • Health Care for the Homeless (HCH) Programs, funded under 330(h); and
  • Public Housing Primary Care (PHPC) Programs, funded under 330(i).

COSTS
HRSA will pay the following annual and on-site survey fees for initial and re-accreditation of health centers if they choose accreditation from the AAAHC or TJC:

  1. Ambulatory care services
  2. Behavioral health services (except for SAMHSA-supported OTP – see below).
  3. Laboratory services that are moderate or high complexity and required by CMS and the Clinical Laboratory Improvement Amendments (CLIA) to be surveyed biennially.
  4. To expand clinical services requiring an extension survey.
  5. Patient Centered Medical Home or Primary Care Medical Home (PCMH) Option.

Health centers bear the responsibility to pay for the following:

  • All other applicable annual and on-site survey fees (e.g., home care, long-term care, conditional follow-up surveys, clarification validation surveys, evidence of standards compliance surveys.
  • On-site Substance Abuse and Mental Health Services Administration (SAMHSA) supported opioid treatment programs (OTPs).
  • Extension surveys not related to clinical services expansion or for the convenience of the health center.

ACCREDITATION ORGANIZATIONS
HRSA/BPHC contracts with two national accrediting organizations to provide survey services under the Accreditation Initiative. Health centers must choose the organization with the services and supports that meet the quality needs of their organization. Direct questions regarding services and educational opportunities provided by either the Accreditation Association of Ambulatory Health Care (AAAHC) or The Joint Commission (TJC) to the contact persons listed below:

POLICIES
The Program Assistance Letter (PAL) 2009-12 Accreditation Initiative Update, describes the survey services, technical assistance and training available to health centers under the Accreditation Initiative.

HOW TO APPLY
Initial Surveys 
Health centers seeking an initial survey must submit a Notice of Interest (NOI) (PDF - 148 KB) to : AccreditInit@hrsa.gov. Once the NOI is submitted, HRSA will review and notify via email each health center and the selected accrediting organization of its approval status. The accrediting organization will directly contact the health center to begin the survey process.

Health centers will receive support in their preparation for their initial survey through a self-assessment or mock survey. Health centers requesting a self-assessment survey should contact Accreditation Association for Ambulatory Health Care (AAAHC) exit disclaimer. Requests for a mock survey should be sent to The Joint Commission’s affiliate, Joint Commission Resources (JCR). All requests should indicate participation in the HRSA Accreditation Initiative, and include a short description of the reason(s) for requesting this assistance and the preferred month for undergoing the mock survey.

Patient Centered Medical Home Option
Eligible health centers may receive Patient Centered Medical Home (PCMH) recognition status through the accreditation PCMH option.

  • Health centers seeking PCMH recognition as an optional component of their ambulatory survey are not required to submit an additional NOI.

Re-Accreditation Surveys
Eligible health centers may preserve their accreditation status through re-accreditation.

  • Health centers seeking re-accreditation are not required to submit a NOI and supporting documentation.
  • The accrediting organization will contact eligible health centers for resurvey under the HRSA Accreditation Initiative.
  • A NOI is required if an accredited health center seeks to change its status with one survey organization and seek status with the other accrediting organization.

TRAINING AND EDUCATIONAL RESOURCES
Health centers participating in the Accreditation Initiative will receive from the accrediting organization their most current accreditation material. These materials will include the AAAHC’s or TJC’s accreditation manual or handbook, newsletters, and other publications to inform health centers about the survey methodology and to help in performance measurement.

The accrediting organizations will make available:

  • Customized educational and training sessions lasting three hours or less, in conjunction with other organizations (e.g., health center, primary care association, regional or national organization representing health centers, and clinical network). These sessions may be tailored to the health center’s specific area of interest.
  • Webinars on the ambulatory care standards and survey processes in health centers.
  • Customized teleconferences with individual or groups of health centers’ leadership, clinical staff, or board members regarding the benefits, obstacles, resources, and preparation steps relating to accreditation standards and maintaining continuous compliance.

To request a training session, a health center should contact either AAAHC or TJC for approval.

TECHNICAL ASSISTANCE FOR THE CY2010 ACCREDITATION INITIATIVE

The PAL for the Accreditation Initiative is located at Program Assistance Letter (PAL) 2009-12.

For further information and/or questions on the Accreditation Initiative, please contact: