to main content Lessons Learned from an Accredited and PCMH Certified Federally Qualified Health Center | The Joint Commission
Ambulatory Buzz

Information on all things ambulatory from The Joint Commission

Lessons Learned from an Accredited and PCMH Certified Federally Qualified Health Center


By Pearl Darling, MBA, Executive Director, Ambulatory Health Care Accreditation

Federally qualified health centers (FQHCs) have undergone enormous transformation during the COVID-19 pandemic. The Joint Commission accredits more than 250 community health centers and these organizations played a monumental role during the pandemic.

Commonly referred to as the “safety net” primary care providers, FQHCs typically serve minority and low-income populations. These health centers were instrumental in vaccinating higher rates of people of color than their counterparts. Read more about the amazing strides FQHCs made in reducing racial disparities in COVID-19 vaccination in this blog by the Kaiser Family Foundation.

FQHCs have been keeping pace with every step of the pandemic and now many are offering free at-home COVID-19 tests. They’ve made tests available at the same pace or sooner than many retail pharmacies while working with far fewer resources.

It doesn’t surprise me in the least that these health centers have been setting the bar. One of the health centers that I’ve really enjoyed working with over the years is Fair Haven Community Health Center (FHCHC), which was one of the first FQHCs in the state of Connecticut to achieve Joint Commission accreditation. They also have The Joint Commission’s Primary Care Medical Home (PCMH) Certification, which recognizes organizations providing access to primary care and offers the potential for increased reimbursement. 

Accredited since 1999, FHCHC’s PMCH Certification journey began in 2015. Some of these successful strategies implemented by FHCHC may be helpful to other organizations considering PCMH Certification: 

1. Utilizing the self-assessment tool. This helps identify gaps so organizations can prioritize where they need to be dedicating resources and identify a readiness date for the onsite survey. 

For FHCHC, this was especially relevant since more than half of its patients speak Spanish and the self-assessment considered patient education, including determining health literacy and addressing comprehensiveness of care.

2. Involving multiple departments. FHCHC convened an ad hoc interdepartmental committee to focus on preparing for PCMH Certification. Departmental leaders involved included:

  • Compliance
  • Chief Medical Officer
  • Human Resources
  • Nursing
  • Operations
  • Patient Access
  • Quality Improvement

The committee met weekly and prioritized obtaining buy-in from other stakeholders. 

Additionally, FHCHC did not forget to engage the Board of Directors. While the Board was familiar with the accreditation process, FHCHC offered a special presentation regarding the added value of seeking PCMH Certification. 

3. Studying the differences between accreditation and other requirements. For example, the Bureau of Primary Healthcare’s guidelines somewhat overlap with The Joint Commission, but key differences include:

  • surveyor participation in the patient care encounter
  • emphasis on infection prevention and control

4. Embracing continued readiness. FHCHC’s accreditation committee has very broad representation throughout the system and is informed by SAFER® Matrix analytics from recent Joint Commission visits. This accreditation committee is charged with keeping abreast of Joint Commission requirements and activities to support both ambulatory care accreditation and PCMH Certification. Its continuous readiness activities, honed over many years, include:

  • accreditation committee meetings
  • gaming with prizes
  • board of director training
  • all staff meetings
  • SAFER Matrix analysis

These activities complement each other to keep readiness top of mind and to reinforce practices that are already strong.

If you have any questions about ambulatory care accreditation or PMCH Certification, please visit our website. Built into the ambulatory onsite accreditation survey, organizations successfully completing this process will be both Joint Commission accredited and certified as a PCMH.

Special thanks to Robyn Hoffman, FHCHC’s corporate compliance officer, and our advisory council member, for sharing her story.  

FHCHC, located in New Haven, Connecticut, was established in 1971 by Latino activists to provide equitable, high-quality, and culturally responsible patient-centered care to improve the health and social well-being of the communities it served. Now, with 15 sites in New Haven, Branford and East Haven, FHCHC serves almost 27,000 patients who made more than 87,000 visits in 2020.

Pearl Darling, MBA, is the executive director for the Ambulatory Care Accreditation Program at The Joint Commission (TJC). In this role, she directs business development, strategic direction and overall product line management for Ambulatory Care Services.  She also serves as a board member on the ASC Quality Collaboration (ASC QC). Previously, Ms. Darling served as Associate Director for Ambulatory Care. Darling has been with The Joint Commission for over 19 years.