Incomplete processes, insufficient documentation were top concerns in HFAP surveys

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June 13, 2019

By Jay Kumar

A new report released by the Healthcare Facilities Accreditation Program (HFAP) says its surveyors found that in 2018, healthcare organizations had the most problems with the development of policies, alignment of procedures, and completion of assessments.

According to the 2019 HFAP Quality Review, incomplete processes and insufficient documentation were the most-cited standards during 2018 on-site surveys at acute care hospitals, critical access hospitals, laboratories, and ambulatory surgery centers.

“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, in a release. “The review can act as a self-assessment guide with tips organizations can use to correct deficiencies they self-identify. Understand 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.”

As is the case with other accrediting organizations, the most frequently cited standards were related to Life Safety Code® compliance. These included 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 codes.

Another area in which organizations struggled was developing and implementing a quality assessment and performance improvement (QAPI) plan that addressed all services provided. QAPI plans are meant to help identify areas of poor performance and lead to changes to improve patient outcomes, according to the HFAP release. Infection prevention and control was a concern, with many acute care hospitals struggling to maintain an active surveillance program with appropriate interventions. Citations included outdated policies, inconsistent cleaning methods, and storage issues.

Emergency management deficiencies were found mainly in acute care and critical access hospitals, with citations centered around having an incomplete emergency operations plan that failed to meet several standards requirements. These included failing to do the following: designate specific responsibilities and service capabilities, establish nutritional services policies, ensure sufficient medical supplies, and assess specific needs for at-risk patients.

The top issues found in clinical laboratory facilities were focused around the processes and procedures involved in analytic systems and proficiency testing. Unsuccessful participation in proficiency testing can lead to restrictions on a lab’s ability to continue testing in areas of deficiency, according to HFAP. Many labs failed to demonstrate that a lab director approves and regularly reviews all procedures and that all manuals and documentation are updated whenever a procedure is changed. Many citations also resulted from expired certification of instruments used for measurement, improper label of expiration dates, and noncompliance with manufacturers’ maintenance recommendations for equipment.






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