HFAP Releases Annual Quality Review


HFAP Releases Annual Quality Review

The recently released 2020 HFAP Quality Review shares key insights and industry trends based on surveyors’ ratings of compliance during 2019 onsite surveys of acute care hospitals (ACH), critical access hospitals (CAH), laboratories and ASCs, according to an August 26 press release.

Analyzing specific areas for improvement in Healthcare Facilities Accreditation Program (HFAP)-accredited healthcare organizations, the report highlights common citations such as insufficient documentation and inconsistent compliance with processes and procedures.

As in previous years, surveyors commonly found deficiencies related to the management of the built environment and its impact on patient, staff and visitor safety, particularly with regard to infection control, according to the release. Common examples included issues with eye wash stations, non-compliant air-pressure relationships, and defects in ceiling, wall, floor and other surfaces.

Life Safety Code standards contributed to the physical environment citations. Examples of this year’s deficiencies include compliance with standards for smoke alarms and other utility systems, such as emergency generators, as well as compliance with requirements for doors located in exit halls.

While infection prevention and control (IPC) citations for ACH dropped to 55 percent from 68 percent in 2018, IPC did remain the most frequently cited deficiency in 2019. Surveyors identified specific failures of cleanliness and failure to follow policies as written. A few examples include no HEPA filter, construction spaces not being maintained in a negative pressure state, containment barriers being compromised by staff for ease of circulation, and inappropriate traffic flow in the sterile and clean supply rooms.

Deficiencies in emergency management remained prevalent in ACH and CAH, specifically the need for a comprehensive emergency preparedness plan that meets the health, safety and security needs of staff, patients and the community.

Specific citations related to emergency management in 2019 include not having an emergency operations plan (EOP) that considers at-risk individuals, identifies services that hospitals will provide under activation of the plan, and addresses the need for nutritional services.

In 2019, an average of 3.85 citations were made at surveys of CLIA laboratories, which was a significant improvement from 7.6 in 2018, but the HFAP Quality Review still reports a need for improvement. The top laboratory facility deficiencies centered on testing personnel competency and evaluation, and proficiency testing. Examples cited circumstances in which the direct observation checklist sheets for competency evaluation were signed by the testing personnel, but not signed or dated by the technical consultant or the laboratory director. In cases when proficiency testing was an issue, laboratory documentation was very brief, leaving questions unanswered.

“The Quality Review plays a vital role in our commitment to help continuously improve the quality of care that HFAP-accredited organizations provide,” said Meg Gravesmill, chief executive officer of AAHHS/HFAP, in the release. “This can be used as a self-assessment guide and should be reviewed by organizations as they evaluate their yearly performance. In light of the global pandemic, it is especially important for organizations to heighten awareness of infection prevention and emergency management standards.”