Hospitals, ambulatory surgery centers and laboratories can now access Meeting the Challenge, the newly released 2021 Quality Review from Accreditation Commission for Health Care (ACHC) for settings accredited through its HFAP programs. The annual analysis of accreditation survey data synthesizes surveyor reports to provide useful benchmarking information for a variety of health care environments.
The report shares key insights and highlights the deficiencies noted during 2020 surveys of acute care hospitals (ACH), critical access hospitals (CAH), laboratories and ambulatory surgery centers (ASC).
The annual publication is designed to help healthcare organizations learn from their peers, overcome common challenges and promote continuous quality improvement.
“The review is intended to be used as a self-assessment guide and reviewed by all organizations to evaluate their yearly performance – akin to an internal audit tool,” says José Domingos, president and CEO of ACHC.
The data is presented by organization type and includes examples of surveyor findings along with useful, actionable tips for improvement in the respective environments. Program leaders looked retrospectively at data to gain insights. “In addition to identifying the standards that are repeat top deficiencies from last year, we also looked back to the last triennial survey year for hospitals and ASCs and biennial survey for laboratories to evaluate whether organizations continue to struggle with the same requirements across survey cycles,” noted Deanna Scatena, associate program director, Acute Care Hospital/Critical Access Hospital.
Key findings include:
- Acute Care Hospitals – Infection control was a significant focus in 2020, as there were both updates to the standards and the challenging circumstances of the COVID-19 pandemic. Thirty-nine clinical and administrative standards were cited as deficiencies at 20% or more of ACHs surveyed. Some areas of concern included risk mitigation, environmental surveillance, and contact isolation signage.
- Critical Access Hospitals – This year, 22 clinical and administrative standards were cited at 20% or more of CAHs. Five standards were cited most frequently, and four of those were related to infection control with the pandemic being an important contributor.
- Laboratory Deficiencies – Clinical laboratories managed high testing volumes, demand for rapid turnaround time, and supply chain constraints related to the pandemic, while still managing the “normal” process of diagnosing testing in support of clinical, infection control, and public health decisions. Seven standards were found to be deficient on more than 10% of surveys performed in 2020, including emergency shower facilities, testing personnel competency and evaluation, quality control for waived tests, verification of performance specifications, maintenance checks, and comparison of test results.
- ASC Deficiencies – Of the 19 top deficiencies for ASCs, five stood out in terms of frequency. Improvement opportunities center on issues related to governing body responsibility for oversight of all aspects of the ASC’s operations and appropriate documentation.
Areas Needing Improvement
The report further identified areas for continued improvement in adherence to environmental and life safety standards:
- Emergency Management – Only four standards were found to be frequently deficient for surveys performed in 2020. The recent shared experience with the public health emergency has vividly illustrated the need for effective emergency management planning that engages all hospital departments. Planning for specific patient population needs and nutritional services were areas of frequent concern in hospitals.
- Physical Environment – Surveyors drew parallels between deficiencies cited in 2020 and the most common deficiencies from previous years, citing medical equipment maintenance, and ventilation, light, and temperature control among key areas for improved compliance.
- Life Safety – A total of 15 life safety standards were frequent deficiencies for acute care hospitals, while 13 standards were frequently cited for critical access hospitals. Fire alarm systems, fire prevention plans, door locks, and elevator recalls were noted across settings.
“The Quality Review is one of many educational reports provided as part of our commitment to a peer-based, holistic accreditation process,” says Domingos. “It continues to serve as a resource to help organizations manage risk, promote quality care for their patients, and build operational efficiencies.”