HFAP survey earns facility referral status

Stays with JCAHO, now has two certifications

(Editor’s note: In the cover story for our September 2003 issue, we examined the growing number of alternatives to JCAHO accreditation. This article takes a closer look at one facility that chose such an alternative and why.)

Russell Medical Center in Alexander City, AL, recently completed a survey process with the Healthcare Facilities Accreditation Program (HFAP) of the American Osteopathic Association (AOA), which has deeming authority to survey hospitals under the Medicare Conditions of Participation. (HFAP is designed to service allopathic [MD] and osteopathic [DO] facilities alike.)

However, Russell didn’t abandon its ongoing relationship with the Joint Commission on Accredi-tation of Healthcare Organizations (JCAHO), but rather sought the additional HFAP accreditation to obtain a status unavailable through JCAHO.

"We were going for a Rural Referral Center status, and one of the requirements was a certain level of admissions," notes Jan Landers, MT (ASCP), MBA, Russell’s director of quality services and corporate compliance. "We didn’t have enough admissions to be recognized by JCAHO, but we did with AOA, and we met all the other criteria."

(With such status, Landers explains, you can get patients referred to your facility from various other rural community hospitals in the area.)

There are distinct differences between the two survey processes, Landers notes. "AOA is more document-driven, and JCAHO is more outcome-driven, though both have obvious benefits," she explains. "AOA is based almost entirely on Medi-care conditions of participation."

By document-driven, Landers notes that AOA actually wants to see what you have on paper. "In terms of patients’ rights, for example, the conditions of participation require that there be a certain number of items patients should be told they have a right to," Landers says. "The AOA will look at the actual paper you give to the patient and check those items off one by one. JCAHO is not quite that way; they would go to the patient and say, Were you told about your rights?’"

The other significant difference, Landers notes, is that there’s not a lot of "surveyor bias" with the AOA. "They go straight by the book," she says. "You either have it, or you don’t."

Once Russell made the decision to undergo the HFAP survey, it only had nine weeks to prepare. "We knew we had a lot of work to do in a very short period of time," Landers recalls.

To help in that preparation, "We spent a little money on a nurse consultant and an administrator consultant, much like you can do with JCAHO," she says. "They both looked at our facility and made suggestions."

That was money well spent, Landers says, because there were no surprises in the survey process. "They were very good consultants," she asserts.

For the immediate future, Russell does not plan to substitute the HFAP survey for JCAHO, but to keep both, despite the obvious financial burden. "We don’t see [HFAP] as a replacement; we will keep doing both," she asserts. "We like the JCAHO approach, as well; it’s expensive, but we really like to be checked on our outcomes as well."

If it is financially plausible, she says, other facilities should consider going with both surveys. "These are really two different approaches and two different surveys; if you have the money in the budget, it’s good to do them both."

Need More Information?

For more information, contact:

Jan Landers, MT (ASCP), MBA, Director of Quality Services and Corporate Compliance, Russell Medical Center, P.O. Box 939, Alexander City, AL 35011. Telephone: (256) 329-7100.

For information on the Healthcare Facilities Accreditation Program, go to: