Accreditation/Certification of Hospitals and Health Centers

Refer to: OPH

1. PURPOSE.

   This Indian Health Service (IHS) Circular expands the options available to the IHS patient care facilities for required accreditation/certification.  Tribally operated and urban health programs are encouraged to obtain and maintain accreditation/certification.

2. BACKGROUND.

   The IHS provides a comprehensive health services delivery system for American Indians and Alaska Natives (AI/AN) with opportunity for maximum tribal involvement in developing and managing programs to meet health needs.  The goal of the IHS is to raise the health status of the AI/AN people to the highest possible level.

   The IHS reaffirms its commitment to quality health care through this Circular.  This Circular provides for choice among nationally accepted accrediting/certifying bodies, e.g., the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Health Care Financing Administration (HCFA), and the Accreditation Association for Ambulatory Health Care (AAAHC), etc.  Accreditation/certification of Indian or tribally operated facilities is negotiated individually with each tribe, Indian organization, or Alaska Native group.

3. POLICY.

   All IHS facilities must meet the requirements of a nationally recognized accrediting or certifying body.  Accrediting organizations used by the IHS must meet the requirements for reimbursement from private insurance, Medicare, and Medicaid under the applicable State plan.  Responsibility and accountability for assuring compliance with these requirements rests with the appropriate Area and Service Unit Director (SUD).

4. TRACKING.

   Headquarters.  The Office of Public Health (OPH) tracks the accreditation/certification of each IHS facility, maintaining a current list for reporting and other purposes.

5. REPORTING.
   1. Area.  Each Area Director is responsible for reporting annually to the OPH on the accreditation/certification status of each IHS facility within their respective Area.
   2. Service Unit.  Each SUD is responsible for ensuring that applicable standards are met and for reporting annually to the Area Director on the accreditation/certification status of each IHS facility within their respective Service Unit.

6. SUPERSEDURE.

   This Circular supersedes IHS Circular No. 81-9 "Compliance Standards with the Joint Commission on Accreditation of Hospitals and Health Care Financing Administration," dated November 27, 1981.

7. EFFECTIVE DATE.

   This IHS Circular is effective upon date of signature by the Director, IHS.