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 3 year contract (April 2006 – March 2009), 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 accreditation fees for health centers both seeking initial and re-accreditation. In addition, BPHC also covers on-site survey fees when a lab accreditation survey occurs in conjunction with the ambulatory care survey. Note: BPHC payment of the indicated survey fees will apply under the Joint Commission's new subscription billing approach.
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/review 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 coordinates with the health center's staff to obtain initial documentation, an application for accreditation, and a confirmed survey date. Although the length of the survey depends on an organization's scope of services, number of and distance between sites, and patient volume, 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 #2005-03 at 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 vice-treasurer, and a patient/user from the Board of Directors;
- A Clinical Leadership/Staff Discussion Session with a cross-section of representatives from all clinical disciplines is added to the survey activities;
- The Joint Commission surveyors review and validate the health center's 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.1.30;
- Relative to HRSA's Office of Performance Review (OPR) Performance Review Protocol, centers scheduled for survey in 2005 won't have an OPR review in 2005 (other accredited centers are eligible for OPR review in 2005). Also, if a center is scheduled for a survey in 2006, they will not have an OPR review in 2006. Pilot testing of a coordinated Joint Commission survey and OPR review will occur in both 2005 and 2006. 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/review 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 project officer, Sonsy Fermin at (301) 594-4296.