In October, 1996, the federal BPHC began an initiative to promote accreditation of BPHC-supported health centers and reduce duplication with its own monitoring. Under the current Accreditation Initiative, and the Joint Commission’s renewed contract (October 2009 – September 2012), BPHC's statutory requirements described in their Program Expectations (formerly called the Primary Care Effectiveness Review or PCER) and the Joint Commission ambulatory care survey are combined into one unified process. A major benefit for health centers is that for the duration of the contract with the Joint Commission, BPHC pays ambulatory care-related on-site and annual accreditation fees for health centers both seeking initial and re-accreditation. In addition, BPHC also covers fees when a lab accreditation survey occurs in conjunction with the ambulatory care survey. The behavioral health annual and on-site fees, and as of September 2008 all on-site and annual laboratory fees.
Also the program is designed to:
- Increase health centers' competitiveness in the marketplace; and
- Provide a structure for health centers to integrate ongoing quality improvement into their daily operations
- Increase patient safety and enhance health care quality
The additional documents and requirements for this unified survey/review are categorized as follows:
The unified survey process encompasses both the BPHC statutory requirements and all applicable Joint Commission standards in the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC). Once BPHC has approved a health center's Letter of Interest to participate in the Accreditation Initiative for the first time (centers being resurveyed are automatically approved), The Joint Commission works with the health center's staff to finalize an application for accreditation, confirm a survey date, identify and provide other assistance that may be helpful. Although the length of the survey depends on an organization's scope of services, number of and distance between sites, and number of patient visits, the most common length is two to three days. A clinician and administrator surveyor from The Joint Commission usually participate in each survey. (see the sample survey agendas for BPHC-supported health centers within the On-site Survey Process section). If the center is also eligible for a laboratory accreditation survey (for centers performing moderate or high complexity laboratory tests as determined by the Clinical Laboratory Improvement Amendments of 1988), a laboratory surveyor also joins the team, although not necessarily for the same number of days.
Lastly, the following materials may be helpful in preparing for survey. (see Preparing for Survey)
A summary of the special features of the unified BPHC/Joint Commission survey is as follows:
- Centers being surveyed for the first time must be accepted into the Accreditation Initiative after submitting a "Letter of Interest" to BPHC (instructions for submission are detailed in a BPHC policy information notice #2007-17at http://www.bphc.hrsa.gov/policy/; centers that are already accredited are automatically approved for resurvey);
- The application for accreditation is good for one year;
- The health center needs to have available on-site additional presurvey materials (this includes the most recent BPHC Notice of Grant Award; the Health Care Plan and Scope of Services from the latest BPHC grant application; minutes from Board meetings; the Quality or Performance Improvement Plan);
- Relative to the BPHC's expectations under the Federal Tort Claims Act (FTCA), see Policy Information Notice #2002-02 (http://www.bphc.hrsa.gov/policy/)
- A Governance Discussion Session is added to the survey activities and requires attendance of at least the Board chairperson or vice-chairperson, the treasurer or Finance Committee chair, and a patient/user on the Board of Directors;
- A Clinical Leadership and Staff Discussion Session with a cross-section of representatives from all clinical disciplines is added to the survey activities;
- The Joint Commission surveyor(s) review and validate the health center's BPHC Self-Report Tool;
- Additional documents are required during the on-site survey
- Any surveyor findings from their assessment of BPHC statutory and regulatory requirements are incorporated as part of the Joint Commission scoring and follow up under Leadership standard LD.04.01.01;
- Relative to HRSA's Office of Regional Operations ( formerly Office of Performance Review) Performance Review Protocol, the limited number of centers scheduled for survey in a calendar year will not have an OPR review that calendar year. See table/diagram summarizing the overlap between the Joint Commission, OPR, FTCA and HIPAA.
Lastly, for more information about the unified BPHC/Joint Commission survey process, please contact at the Joint Commission either Lon Berkeley, Project Director for Community Health Center Accreditation, at (630) 792-5787, Rex Zordan, Account Representative (630) 792-5509, Delia Constanzo, Administrative Coordinator (630) 792-5011, or the BPHC/Accreditation Initiative Program Director, Vanessa Watters at (301) 594-4070.