Most Frequently Cited Standards Focus on the Details of Healthcare Policies, Procedures
(Chicago) May 10, 2018 – According to the newly released 2018 HFAP Quality Review, compliance with accreditation standards calling for complete, detailed policies, procedures and assessments proved the most difficult to demonstrate for all types of organizations. Many healthcare facilities overlook key specifics of the requirements.
The 2018 HFAP Quality Review shares key insights and industry trends extracted from surveyors’ ratings of compliance during 2017 onsite surveys. HFAP accreditation experts reviewed the surveys of acute care hospitals, critical access hospitals (CAH), laboratories and ambulatory surgery centers (ASC) to identify the top deficiencies cited throughout the year, and provide examples to help organizations avoid common pitfalls. Lack of consistency, proper documentation and procedural review contributed to the majority of deficiencies in 2017.
“The Quality Review is designed not only to deliver a list of top deficiencies, but also provide examples of common errors and tips on how to overcome these obstacles to achieve and maintain accreditation,” said Meg Gravesmill, CEO of HFAP. “When preparing for accreditation, healthcare organizations need to know the ins and outs of each standard to better understand how to reach full compliance and incorporate best practices into daily routines. When the steps become second nature, it is easier for different teams to work synergistically and strengthen consistency, efficiency and overall organizational performance.”
Deficiencies surrounding the physical environment were significant in acute care hospitals, CAHs and ASCs. These standards focus on how the management of the built environment can impact patient, staff and visitor safety. The most frequently cited standards were typically the result of cumulative deficiencies in Life Safety and Physical Environment standards.
Some common examples of these deficiencies include insufficient emergency supplies, untested fire alarm and sprinkler systems, incomplete risk assessments of building services, and failure to comply with National Fire Protection Association (NFPA) codes.
To overcome these deficiencies, HFAP experts recommend healthcare organizations review the requirements of Life Safety, Physical Environment and Emergency Management standards to ensure they have the proper assessments and checklists in place. This will require cooperation and collaboration between engineering teams that manage the physical facilities and clinical care supervisors.
Patient Care and Safety
In terms of standards associated broadly with patient care and safety, ASCs continue to struggle with developing a comprehensive credentialing and privileging process that includes the appropriate documentation and reappraisal procedures. ASC medical records may leave patient history and physical updates incomplete. Infection prevention and control protocols including hand hygiene continue to be inconsistently implemented. These deficiencies can be remedied with improvements to internal procedures and oversight to document each step in the process.
In the acute care and CAH settings, hospitals need improvement in their infection prevention and control risk assessments, often due to conflicting internal policies that impact the assessment and maintenance of the facilities. Many hospitals fail to meet the informed consent requirement that calls for use of simple language to ensure the patient understands his or her treatment plan when discussing it with a provider. Informed consent is necessary to demonstrate engagement between patient and provider, and confirms that an explanation of options was presented that the patient can comprehend and repeat.
The top deficiencies cited in laboratory facilities centered on the procedures involving analytic systems. All laboratory procedures must be approved by the laboratory director with regular reviews to ensure they are supporting best practices, which many facilities fail to demonstrate due to lack of documentation or incomplete processes.
In addition, many laboratories struggle to fully comply with manufacturers’ instructions for use of tests and equipment, as well as implement consistent maintenance and assessment policies for ongoing quality control. Creating a detailed checklist and regular assessment schedule can help create a uniformed process for quality control. Missing or incomplete policies on reagent kit components also is a top concern for laboratories, and can be corrected with stronger processes and oversight, the HFAP Review notes.
New requirements from the Centers for Medicare and Medicaid Services (CMS) went into effect November 15, 2017. To help healthcare organizations comply with the new regulations, HFAP included best practices for tracking patients and staff, and ensuring a shelter in place option during an emergency event.
“To manage an emergency situation, facilities must have airtight procedures in place that clearly identify everyone’s roles and collect up-to-date information to support decision making,” said Gravesmill. “The new CMS requirements call upon organizations to develop “all risk” strategies to build comprehensive action plans. In a crisis scenario, the details matter. Thoroughly preparing enables organizations to iron out the details and correct any errors before an actual emergency occurs, leaving them better equipped to handle a crisis.”
To download the 2018 HFAP Quality Report or for more information on the HFAP accreditation process, please visit www.hfap.org.
HFAP is a nationally recognized not–for–profit accreditation program with deeming authority from the Centers for Medicare and Medicaid Services for hospitals, laboratories, and ambulatory surgery centers. HFAP’s programs focus on supporting customer success in meeting the standards through a collaborative and educational accreditation process focused on the unique needs of each facility.