Bureau of Primary Health Care
Accreditation Initiative

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There has been an increased effort from the Bureau of Primary Health Care (BPHC) to expand the Accreditation Initiative for federally supported Health Centers.  In September 2009, the AAAHC was awarded a three-year contract to participate in this Initiative.  BPHC’s requirements and the AAAHC standards for accreditation have been combined into a unified process.  A major benefit of the Accreditation Initiative is that the BPHC will pay the Health Center’s fees associated with the accreditation survey, including the AAAHC Application and Accreditation Handbook for Ambulatory Health Care.
Health Centers interested in BPHC support for AAAHC accreditation should first forward a Notice of Interest (NOI) directly to the Accreditation Initiative Program at accreditationinitiative@hrsa.gov.

PLEASE NOTE:  It may take several days for HRSA to respond to your request.

The Accreditation Initiative is designed to:

1. Provide a venue for Health Centers to integrate, monitor and improve the quality of health care,
2. Increase patient and staff safety, and
3. Increase a Health Center’s marketability within the community.

AAAHC Survey

The AAAHC survey process is designed to be educational and interactive; AAAHC surveyors are established health care professionals who bring a real-world work experience to the survey.  Health Centers will be surveyed against current BPHC expectations and AAAHC standards; during the survey AAAHC surveyors may also offer suggestions and consultative comments relating to how specific processes may be improved.   
While a final determination of the scope (length of and number of surveyors needed) of survey cannot be established until a completed Application for Survey is received, most Health Centers can plan for a survey to be performed over a 2.5 day period by a team of 2 surveyors. The AAAHC will work with the Health Center to identify survey dates that accommodate its schedule

Survey Preparation

The AAAHC will work directly with Health Centers to help prepare for survey.  
1. The AAAHC offers several materials to help prepare for survey.  Among the materials offered include:  the Accreditation Handbook for Ambulatory Health Care, the Self-Assessment Manual and a Self-Reporting Tool.
2. The AAAHC offers an Accreditation Readiness packet.  This Packet is intended to ensure that Health Centers are familiar with the AAAHC accreditation process and responsibilities of both the AAAHC and the Health Center during the survey.  
3. Additional pre-survey activities will also include a pre-survey assessment performed by an AAAHC surveyor.
For a listing of the standards that are applicable to the survey: AAAHC Standards


Compliance to AAAHC standards may be determined by the following:
1. Documented evidence, (e.g., chart review, policies and procedures, credentialing and personnel records, etc.)
2. Answers to detailed questions concerning implementation, (e.g., staff interviews)
3. On-site observations and patient interview(s) by surveyors
The AAAHC also offers a Self-Reporting Tool that Health Centers should utilize to help determine compliance to the expectations of the BPHC.  This tool can also be used to identify the strengths of the Health Center and those areas where improvement is needed.  Health Centers should complete this Tool prior to survey, be able to provide a completed copy to the survey team and be prepared to discuss its responses with the survey team.

Accreditation Term

Health Centers that are found to be accreditable will be awarded a three-year term of accreditation.  
While accreditable Health Centers will be awarded a three-year term of accreditation, a plan of correction (POC) may be required when a portion of the Health Center’s operations is acceptable, but other areas need to be addressed/improved upon.  The POC should identify the steps and actions the Health Center will take to correct those non-compliant findings, in order to bring those areas to an acceptable level of performance.


Initial Surveys
Health center seeking an initial survey must submit a Notice of Interest (NOI) to accreditationinitative@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 AAAHC.

For Additional Information

To access the HRSA/BPHC website, go to: HRSA/BPHC

To request additional information on AAAHC Health Center accreditation or the materials that are needed to help ready a Health Center for survey, please contact Ron Smothers, Project Manager for Community Health Center Accreditation at 847 853-6060, or via e-mail: rsmothers@aaahc.org


The Notice of Interest (NOI). This is the form you must complete and submit directly to the Accreditation Initiative Program at accreditationinitative@hrsa.gov.

The “Accreditation Initiative Resources”. This is a downloadable file that presents a side-by-side comparison of the accreditation services provided by the Accreditation Association for Ambulatory Health Care and The Joint Commission. 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. This resource allows health centers to choose the accreditation organization that best meets the needs of their organizations.