Accreditation - North Florida/South Georgia Veterans Health System
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North Florida/South Georgia Veterans Health System

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Joint Commission

The North Florida/South Georgia Veterans Health System (NF/SGVHS) is accredited by The Joint Commission.  Our medical centers, outpatient clinics, and community based outpatient clinics are regularly reviewed to make sure they comply with the national Joint Commission standards such as safety, quality of patient care, and environmental issues.

Individuals are encouraged to contact NF/SGVHS management regarding any concerns about patient care and safety in the system.  If the concerns cannot be resolved through our organization, you are encouraged to contact The Joint Commission.  The Joint Commission wants to know about it.  Send them your complaint by mail, fax, or e-mail.  Summarize the issues in one to two pages and include the name, street address, city, and state of the health care organization.  When submitting a complaint to The Joint Commission about an accredited organization, you may either provide your name and contact information or submit your complaint anonymously.  Providing your name and contact information enables The Joint Commission to inform you about the actions taken in response to your complaint, and also to contact you should additional information be needed.

It is a Joint Commission policy to treat your name as confidential information and not to disclose it to any other party.  However, it may be necessary to share the complaint with the subject organization in the course of a complaint investigation.

Joint Commission policy forbids accredited organizations from taking retaliatory actions against employees for having reported quality of care concerns to The Joint Commission.

Joint Commission Mailing Address:
Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL  60181

Joint Commission E-mail:

Joint Commission Fax: 630-792-5636

Report a Complaint Online or Find More Information on the Joint Commission Web Site: Report a Complaint to The Joint Commission*

*Link will take you outside of the Department of Veterans Affairs web site.  VA does not endorse and is not responsible for the content of the linked web site.  The link will open in a new window.

If you have questions about how to file your complaint, you may contact The Joint Commission at this toll free number, 8:30 a.m. to 5:00 p.m., Central Time, weekdays: (800) 994-6610.



Commission on Accreditation of Rehabilitation Facilities (CARF)

A private, non-profit organization providing a consultative accreditation process that centers on enhancing the lives of persons served.  CARF currently surveys NF/SGVHS Healthcare for Homeless Veterans (HCHV) and the Compensated Work Therapy (CWT)/Transistional Residency (TR) programs.



Office of Inspector General/Combined Assessment Program (OIG/CAP)

Combined Assessment Program (CAP) reviews are part of the OIG’s efforts to ensure that high quality health care services are provided to our Nation’s Veterans.

CAP reviews combine the knowledge and skills of the OIG's Offices of Healthcare Inspections and Investigations to provide collaborative assessments of VA medical facilities on a cyclical basis. The purposes of CAP reviews are to:

  • Evaluate how well VA facilities are accomplishing their missions of providing Veterans convenient access to high quality medical and benefits services.
  • Provide fraud and integrity awareness training to increase employee understanding of the potential for program fraud and the requirement to refer suspected criminal activity to the OIG.



Association for the Accreditation of Human Research Protection Program (AAHRPP)

Originally incorporated in Massachusetts under the auspices of Founding Member Public Responsibility in Medicine and Research (PRIM&R), and later incorporated as a non-profit organization in Maryland in 2001, the Association for the Accreditation of Human Research Protection Programs, Inc. (AAHRPP) offers accreditation to organizations that conduct or review research with humans.

Responding to increased public concern for protecting research participants, AAHRPP seeks not only to ensure compliance with federal regulations, but to raise the bar in human research protection by helping organizations reach performance standards that surpass the threshold of state and federal requirements.

AAHRPP accredits high quality human research protection programs in order to promote excellent, ethically sound research. Through partnerships with research organizations, researchers, sponsors, and the public, AAHRPP encourages effective, efficient, and innovative systems of protection for human research participants.

System-wide Ongoing Assessment and Review Strategy (SOARS)

SOARS provides assessment and educational consultation to facilities using a systematic method for on-going self-improvement.  They support a continious readiness culture where each person understands the value of their contribution to the VHA mission. 

SOARS Vision:

  • Help provide quality health services to eligible veterans.
  • Assist medical centers with meeting standards of care and reamin continually ready for reviews.
  • Identify strong practices, sharing this information with other networks and medical centers.

College of American Pathologists (CAP)

An accrediting organization that performs unannounced inspections of clinical laboratories, from complex university medical centers to physician office laboratories.

The goal of the CAP Laboratory Accreditation Program is to improve patient safety by advancing the quality of pathology and laboratory services through education, standard setting, and ensuring laboratories meet or exceed regulatory requirements.

It is recognized by the Joint Commission and can be used to meet many state certification requirements.



The Society of Chest Pain Centers

The Society of Chest Pain Centers is a professional accrediting organization focused on heart disease. The goal of the Society is to promote protocol based medicine, delivered through a Chest Pain Center model to address the rapid diagnosis and treatment of acute coronary syndromes, heart failure, and to promote the adoption of process improvement science by healthcare providers.

The Society of Chest Pain Centers granted the designation of Accredited Chest Pain Center to the Malcom Randall VA Medical Center in 2004 and the Lake City VA Medical Center in 2006.  The Malcom Randall VA Medical Center was the first VA hospital in the nation to receive full accreditation status. Accreditation is granted only to the facilities whose Chest Pain Center meets the established criteria.