Accreditation standards requiring detailed policies, procedures, and assessments pose the most problems for hospitals under the Hospital Facilities Accreditation Program (HFAP) based in Chicago.

HFAP recently released its 2018 Quality Review, which analyzes trends from surveyors’ ratings of compliance during 2017 onsite surveys of acute care hospitals, critical access hospitals (CAH), laboratories, and ambulatory surgery centers (ASCs). The report says most 2017 deficiencies were traced to lack of consistency, proper documentation, and procedural review.

Meg Gravesmill, CEO of HFAP, said in a statement accompanying the report that 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.”

These excerpts from the HFAP report highlight the most common deficiencies in 2017:

• Physical Environment: Deficiencies surrounding the physical environment were significant in acute care hospitals, CAHs, and ASCs, related to standards involving how the management of the built environment can impact patient, staff, and visitor safety. HFAP surveyors most frequently cited cumulative deficiencies in Life Safety and Physical Environment standards. Examples 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.

In response, HFAP suggests reviewing the requirements of Life Safety, Physical Environment, and Emergency Management standards and ensuring proper assessments and checklists are in place. Engineering teams need to collaborate with clinical care supervisors.

• Patient Care and Safety: HFAP found that ASCs often fail to develop 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,” the report says. “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.”

Infection prevention and control risk assessments are more of a concern in the acute care and CAH settings, the report says. Problems in this area often are traced to conflicting internal policies that impact the assessment and maintenance of the facilities, HFAP says. “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,” HFAP says.

“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.”

• Analytic Systems: Laboratory facilities most often had issues related to analytic systems. HFAP requires that all laboratory procedures be approved by the laboratory director with regular reviews to ensure they are supporting best practices, but many facilities fail to demonstrate due to lack of documentation or incomplete processes, the report says.

“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,” HFAP reports.

“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.”

• Emergency Management: HFAP provides best practices for tracking patients and staff, and ensuring a shelter in place option during an emergency event, which the group says should help accredited facilities comply with CMS requirements.

The HFAP best practices emphasize the need to create procedures that clearly identify everyone’s roles and collect up-to-date information to support decision-making.

The HFAP 2018 quality report is available online at: https://bit.ly/2x5cNv3.