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U.S. Department of Health and Human Services

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Accreditation

Accreditation Steps
Accredited Indian Clinics

The dictionary defines the word "accredit" as "to certify as meeting a prescribed standard." In order to become accredited, a health program must undergo a comprehensive review by a team of health care professionals from an accreditation organization. During this on-site review, the health program needs to demonstrate how it has complied with the clinical practice standards that the accreditation group has set forth, the Joint Commission Exit Disclaimer: You Are Leaving www.ihs.gov and the Accreditation Association for Ambulatory Health Care Exit Disclaimer: You Are Leaving www.ihs.gov (AAAHC). Residential substance abuse treatment programs may use The Commission on Accreditation of Rehabilitation Facilities Exit Disclaimer: You Are Leaving www.ihs.gov (CARF) for their accreditation.

Why Accreditation?

When people talk about accreditation, they often ask, "Why go to the trouble and expense?" One important reason to become accredited is that accreditation represents the "gold standard" in the health care industry. Accreditation demonstrates to your patients that the organization has "passed the test" and is committed to providing high quality care. Accreditation helps to assure that your clinical staff has a healthy environment to work in, thereby improving quality of care, staff morale, and retention of professionals. Improved marketability and image within the local community is another reason to be accredited. Other health providers and organizations in your region look upon accredited facilities as trusted and proven partners in care.

Accreditation will reduce the frequency of IHS program reviews at your facility. Indian Health Service (IHS) will only check specific IHS standards (such as background checks) and issues found to be out of compliance in an accreditation review instead of doing a complete program review. Finally, and most importantly, doing what it takes to become accredited virtually guarantees the quality of care you provide to your patients will improve.

Accreditation Steps

Once the decision has been made to become an accredited organization, many new issues present themselves. The following information provides some insight into the accreditation process from different perspectives: that of the health board or governing body, the program director, and the accreditation coordinator.

The Health Board's Role

In order to achieve accreditation, the health board must demonstrate its leadership role in the organization by accomplishing the following:

  • Develop a mission statement and organizational by-laws
  • Hire personnel that are competent and capable of providing the necessary services
  • Provide a safe and secure facility
  • Monitor the quality and range of services
  • Provide a sound fiscal environment
  • Develop and implement a policy on patients rights
  • Approve all contracts with local health care practitioners, labs, x-ray, etc.
  • Formulate a long-range plan - What will the clinic look like in 10 years?
  • Develop and implement a risk management program
  • Require that all licensed health practitioners undergo a formal process to verify their credentials
  • Review and approve all requests for privileges by licensed independent practitioners
The Program Director's Role
What is the first step?

Make sure the health program meets the eligibility criteria for accreditation.

The AAAHC eligibility criteria require that the organization:

  1. Has been in operation at least six months.

  2. Is a formally organized and legally constituted entity that primarily provides health care services.

  3. Is in compliance with applicable federal, state, and local laws and regulations.

  4. Is licensed (or certified) by the state in which it is located.

  5. Provides medical care that is under the direction or supervision of a physician or group of physicians.

  6. Shares facilities, equipment, business management, and records involved in patient care among the members of the organization.

  7. Operates without limitation because of race, creed, sex, or national origin. Allowances are made for the legal application of Indian Preference.

  8. Provide applications and documents requested in advance of the survey.

  9. Pays the appropriate fee

  10. Acts in good faith providing complete and accurate information before, during, and after the review.

Who is going to handle accreditation preparation?

Each and every member of the clinic staff and the health board must be involved in preparing for accreditation. A "corporate culture" that values quality improvement activities and the documentation of policies and procedures must be developed and nurtured. Everyone needs to see the benefit of providing care that is up to accreditation standards and not feel that the process is an unnecessary waste of time.

Though everyone is responsible for the work of accreditation, someone has to coordinate the work to insure that all standards are addressed. An employee with good organizational skills can do the coordination job. The designated employee will work with the program director to fill out the accreditation application and will know what policies and procedures exist and where they can be found. The accreditation coordinator has to make sure that each accreditation standard is addressed and be able to lead the accreditation reviewer to its location.

This assignment may be a collateral duty or a full time job. Some sites utilize a nurse, while others feel that a different health professional has more time and energy to devote to the detail required. Whoever is chosen, the individual must have the respect of other workers and be granted the authority to make things happen.

What does the program director do?

The most important job the program director can do is to schedule ample time for the employees to work on the written documentation required by the accreditation reviewers. Usually this means implementing or increasing time allotted for administrative duties. A clinic may reduce their "open hours" to give the staff dedicated administrative work time. For example, every Wednesday, the clinic may open for patient care at 10:00 A.M. instead of 8:00 A.M. so that staff can have two uninterrupted hours for accreditation work.

The Accreditation Coordinator's Role

This sounds like a huge job. How will we ever get it done?

Keep in mind that most health programs are often further along in the process than they realize. Many health programs already have policies and procedures in place for most of the standards. Individual departments may already have started at least some quality improvement activities and Government Performance and Results Act (GPRA) data is a great place to start.

As you go along, you will find that team meetings and staff education are a big part of the process. There should be a constant reappraisal of all departments and standards to insure that accreditation activities and quality improvement monitors are pertinent and comprehensive. You may find improvements in cost containment and clinic effectiveness.

Accredited Indian Clinics

Two Indian health facilities in California have received accreditation through the Joint Commission:

Seventeen Indian health facilities in California are accredited through the Accreditation Association for Ambulatory Health Care (AAAHC):

Two urban Indian residential substance abuse treatment programs are accredited through the Commission on Accreditation of Rehabilitation Facilities (CARF):