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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:
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.
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.”
“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.”
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.
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Jill Winkler, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.