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HFAP Quality Review Shares Expert Tips to Prevent Top Deficiencies

Incomplete processes, procedures and documentation cause majority of citations

The development of policies, alignment of procedures and completion of assessments continue to trouble all types of healthcare organizations seeking accreditation. According to the recently released 2019 HFAP Quality Review, incomplete processes and insufficient documentation remain the main concerns cited during accreditation surveys. To prevent these citations, HFAP recommends healthcare teams review standards by assessing existing policy, implementation, evaluation and reporting practices to ensure all requirements are fulfilled.

The 2019 HFAP Quality Review shares key insights and industry trends extracted from surveyors’ ratings of compliance during 2018 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 provided examples to help organizations avoid common pitfalls. Incomplete processes, documentation and assessments contributed to the majority of deficiencies in 2018.

“The Quality Review is designed to help healthcare organizations evaluate their performance in context with their peers by identifying trends from all surveys conducted throughout the year,” said Meg Gravesmill, CEO of AAHHS/HFAP. “The review can act as a self-assessment guide with tips organizations can use to correct deficiencies they self-identify. Understanding the pattern of policy, implementation, evaluation and reporting for each set of standards supports development of a framework to boost survey performance – which leads to improved quality and safety across the organization.”

Physical Environment

In acute care hospitals, CAHs and ASCs, deficiencies in standards focused on how the management of the built environment can impact patient, staff and visitor safety were commonly reported. Similar to results from previous years, the most frequently cited standards were those related to Life Safety Code compliance.

Some common examples of these deficiencies include poor management of building controls and fire alarm systems, insufficient life safety policies, 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 the HFAP Life Safety and Physical Environment standards, as well as the appropriate NFPA codes, to ensure they have the proper assessments and checklists in place. Engineering and building management teams must work collaboratively with clinical care supervisors to confirm all members of the organization are aware of the requirements.

Patient Care and Safety

One aspect of the standards associated with patient care and safety found deficient across acute care hospitals, CAHs and ASCs was the development and implementation of a Quality Assessment and Performance Improvement (QAPI) plan that addressed all services provided – even those provided through contracts or agreements. The goal of the plan is to provide the foundation for ongoing quality improvement by identifying areas of low performance and deploying changes to enhance patient outcomes. QAPI plans should be broad-based and incorporate all aspects of an organization’s operations.

For deficiencies related to infection prevention and control, many acute care hospitals struggled to maintain an active surveillance program with appropriate interventions across all departments, and failed to integrate the infection prevention and control program with the hospital-wide QAPI plan. A wide range of citations were noted, including outdated policies, inconsistent cleaning methods and storage issues.

While the percentage of infection control-related citations in ASCs dropped from 75% in 2017 to 23% in 2018, difficulty demonstrating consistent cleanliness practices throughout facilities persisted. ASCs also struggled to provide complete patient admission, assessment and discharge documentation, which can increase patient risk due to inaccurate information.

According to HFAP surveyors, the majority of deficiencies reflect infection control issues “hiding in plain sight” that are easily corrected with more thorough and consistent procedures based on the standards.

Emergency Management

Deficiencies in emergency management were most prevalent in acute care hospitals and CAHs. These standards call for the development of a comprehensive emergency preparedness program that complies with local, state and federal requirements and addresses protocols for any type of emergency or disaster.

Citations in emergency management stemmed from an incomplete Emergency Operations Plan (EOP) that failed to meet a variety of standards requirements, including designating specific responsibilities and service capabilities, establishing nutritional services policies, ensuring sufficient medical supplies, and assessing specific needs of at-risk patients.

HFAP surveyors recommend organizations review the standards requirements for a comprehensive emergency preparedness program that is deployed hospital-wide and fully-integrated with the QAPI plan. Hospitals should evaluate and update the EOP annually and provide accurate documentation of all assessments to demonstrate compliance.

Laboratory Analytic Systems

“While general laboratory services are addressed during acute care, CAH and ASC surveys, clinical laboratories undergo unique, biennial surveys to maintain accreditation and Clinical Laboratory Improvement (CLIA) certification,” said Gravesmill. “Staying organized and up-to-date on CMS requirements is key to laboratory success, where insufficient protocol can significantly limit the capabilities of the facility in the future.”

The top deficiencies cited in clinical laboratory facilities centered on the processes and procedures surrounding analytic systems and proficiency testing. Unsuccessful participation in proficiency testing can result in restrictions on a laboratory’s ability to continue testing in areas of deficiency. Many clinical laboratories failed to demonstrate that a laboratory director approves and regularly reviews all procedures, and that all manuals and documentation are updated whenever a procedure is changed.

In addition, laboratories’ management of conditions and supplies were often found deficient. Many citations resulted from expired certification of instruments used for measurement, improper labeling of expiration dates and noncompliance with manufacturers’ maintenance recommendations for equipment.

HFAP surveyors recommend clinical laboratories establish protocol to review all procedures, quality controls, documentation and supplies on a regular basis.

Quality Review Webinars

HFAP will be hosting a series of webinars to discuss the findings of the 2019 Quality Review by organization type. The first of these will take place on July 11 at noon CT and focus on laboratory deficiencies. Registration is open now.

To download the 2019 HFAP Quality Review or for more information on the HFAP accreditation process, please visit



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