Preparing for Accreditation and PCMH Recognition Surveys

Health centers should anticipate spending 9 to 12 months to plan and prepare for initial or renewal accreditation, recognition, or both. More information about the requirements for different accreditation and recognition organizations is found below.

HRSA encourages health centers to:

  • Review resources provided by AAAHC HRSA Exit Disclaimer, TJC HRSA Exit Disclaimer, and NCQA HRSA Exit Disclaimer to assess their readiness to participate and help ensure positive survey outcomes. These organizations developed technical assistance and training resources that focus on strategies for obtaining and maintaining accreditation and/or PCMH recognition status.
  • Utilize the technical assistance resources of their State/Regional Primary Care Associations (PCAs) to support preparation for accreditation site visits or PCMH recognition surveys. Health centers can request a practice facilitation coach from their PCA for assistance.

The accreditation or PCMH survey process will vary depending on the type of recognition/accreditation and organization selected.

Types of Surveys

PCMH Recognition Surveys

Health centers seeking PCMH recognition through NCQA may apply for:

  • Initial recognition surveys cover individual health center sites that are seeking recognition for the first time.
  • Renewal surveys cover individual sites that seek to maintain their PCMH recognition status. NCQA awards PCMH recognition for a period of 3 years.
  • Add-On Surveys to Increase Recognition Level: There are three levels of NCQA PCMH recognition—Level I, II, or III. An already-recognized health center may apply to increase its level of PCMH recognition through the add-on survey process.

Ambulatory Health Care Accreditation

Health centers may apply for on-site initial, re-accreditation, or add-on accreditation.

  • Initial accreditation surveys cover health centers that have not been accredited under the initiative.
  • Re-accreditation cover health centers that seek to maintain their accreditation status. AAAHC or TJC awards accreditation for a period of 3 years; health centers can maintain their accreditation status through the re-accreditation process.
  • Add-on Surveys cover already accredited health centers seeking to add an additional type of survey (e.g., laboratory, behavioral health, or PCHM option).

Accreditation includes:

  • Ambulatory health care services.
  • Behavioral health services (except for SAMHSA-supported OTPs).
  • Laboratory services that are moderate or high complexity and required by CMS and CLIA.
  • Add-On (Adjunct) surveys to expand clinical services requiring an extension survey.
  • PCMH Option: Eligible health centers may elect to receive PCMH recognition for the entire health center organization. Health centers may seek the PCMH option at the same time as their ambulatory care accreditation survey or; an already accredited health center may add the PCMH option by submitting a new NOI to HRSA in the same manner as an initial survey; see Notice of Intent.

Accreditation & PCMH Contacts

Please submit your Accreditation and/or Patient Centered Medical Home (PCMH) requests to the health center APCMH team HRSA BPHC exit disclaimer. To make sure you receive our reply email, add 'BPHCAnswers@hrsa.gov' to your address book.

Accreditation Association of Ambulatory Health Care HRSA BPHC exit disclaimer
Email: HRSA@aaahc.org

The Joint Commission HRSA BPHC exit disclaimer
TJC HRSA Accreditation and Patient-Centered Medical Home Recognition Initiative
Email: hrsaaccreditation@jointcommission.org
Phone Number: (630) 792-5900

The National Committee for Quality Assurance HRSA BPHC exit disclaimer
NCQA Government Recognition Initiative Program HRSA BPHC exit disclaimer
Phone: (888) 275-7585

Related Resources

Select an Accreditation/PCMH Recognition Organization

Submit Notice of Intent (NOI)

Prepare for a Survey

Change Accreditation/Recognition Organizations

Accreditation and Patient-Centered Medical Home Initiative, PAL 2015-02

PCMH Resource Center (Agency for Healthcare Research and Quality)

Date Last Reviewed:  September 2021