5 of the most common deficiencies found by HFAP

The Healthcare Facilities Accreditation Program (HFAP) has released the 2018 edition of its annual quality report, illustrating how deficiencies were most commonly found at the hospitals, clinical laboratories and ambulatory surgical centers (ASCs) it inspects.

“The quality review is designed not only to deliver a list of top deficiencies, but also provide examples of common errors and tips on how to overcome these obstacles to achieve and maintain accreditation,” HFAP CEO Meg Gravesmill said in a statement. “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.”

Here are five deficiencies frequently identified in the report and ways HFAP recommends facilities address them:

1. Physical environment violations

The most frequently cited deficiencies dealt with the physical environment in facilities. HFAP said some common problems found were having insufficient emergency supplies as well as untested fire alarms, sprinkler systems and emergency generators.

For acute care hospitals, defiencies for physical environment were found in 36 percent of surveys in 2017. The rate was higher (39 percent) in critical access hospitals (CAHs). To correct these shortcomings, HFAP recommended facilities go over existing requirements to make the right assessments and checklists are in place.

“This will require cooperation and collaboration between engineering teams that manage the physical facilities and clinical care supervisors,” the report said.

2. Infection control and sanitary environment in ASCs

Infection control protocols, including proper hand hygiene, were inconsistently applied in ASCs. In more than 70 percent of HFAP’s surveys of ASCs, deficiencies were cited related to maintaining a sanitary environment in surgical suites. These included visible accumulations of dust on vents in operating rooms, rust on table frames and dead insects being found on gas valves.

3. Documentation in ASCs

A little under 40 percent of ASCs were cited for deficiencies related to include pre-surgical assessment documentation on a patient’s medical record. This assessment is supposed to be completed by a physician regarding the risk of the procedure, anesthesia and allergies or reactions to drugs.

Sometimes no documentation of allergies was found by HFAP. Other surveyor citations included leaving dates off charts or completing the update more than a week before surgery.

4. Contracted services at hospitals

Around 15 percent of acute care hospital surveys found problems with monitoring quality among services provided by hospital contractors. Even if the service is only being indirectly offered by the hospital through a joint venture or shared arrangement, the hospital’s governing body is still responsible for deficiencies in those services.

HFAP found broken links in the chain of reporting on quality standards for contracted services. Most commonly, reports were submitted but not advanced to a hospital’s quality committee or the committee isn’t assessing those services at all.

5. Telemedicine standards at CAHs

Like acute care hospitals’ standards for contracted services, facilities using telehealth can be cited for that service’s deficiencies. A little more than 15 percent of CAH surveys found problems in these areas, such as leaving physicians off lists of interpretation services or hospitals not reviewing telemedicine agreements in the past three years.