HFAP QUALITY REPORT 2017 A review of stadard deficiecies based o HFAP surveys of: Acute Care Hospitals ad Critical Access Hospitals (CAHs) Icludig Emergecy Maagemet, Physical Eviromet, ad Life Safety Code issues Laboratories Ambulatory Surgical Ceters (ASCs)
FROM THE BOARD CHAIRS This HFAP Quality Report is the first of a plaed aual compilatio ad review of data from surveys coducted the prior year. Surveys from each HFAP accreditatio program are reviewed for o-compliat ratigs by surveyors for each stadard. This report focuses o the most frequet fidigs of deficiecy withi each program, o the prevalet reaso(s) for the fidigs, ad o tips for correctig ad avoidig o-compliace. The top issues i emergecy maagemet, life safety, ad physical eviromet for hospitals are idetified separately. Hospitals, CAHs, Laboratories, ad ASCs ca use this report to: 1. Prepare for a iitial accreditatio survey For a healthcare facility ew to HFAP (or for a idividual i a curretly accredited facility who is ew to the HFAP stadards ad survey process), this report suggests areas i which to begi focused efforts whe preparig for a survey. Look at the stadards oted as the most commo challeges for your peer istitutios. Study the examples of commets made by surveyors to help guide you i preparatio for a successful iitial survey. Reach out to HFAP stadards iterpretatio staff for help. 2. Prepare for reaccreditatio For a facility that is readyig itself for a bieial (lab) or trieial (hospital, CAH, or ASC) survey, this documet should be used i cojuctio with your most recet deficiecy report. Read together, the two will show how your performace compares with that of similar facilities. You may fid that you have already idetified ad addressed the problems that are commoly cited by surveyors for your type of settig, or you may fid it helpful to explore some of the additioal educatioal resources we offer to pre-emptively correct ogoig issues ad improve your performace o your upcomig survey. 3. Coduct a mid-cycle self-assessmet The myth that accreditatio is a cycle of heavy liftig that occurs i the moths just prior to a survey ca be dispelled by shiftig your poit of view. Look to accreditatio as a o-goig cycle of cotiuous improvemet. With that midset, this report ca be a tool for frequet self-assessmet. Rather tha waitig to prepare for reaccreditatio whe the ext survey is i sight, use this report with the curret stadards maual as a framework for regular review of how your facility delivers importat aspects of care ad maitais the physical eviromet. We at HFAP are committed to providig a quality accreditatio experiece focused o your success. We hope that this ew resource is useful ad we welcome your feedback. Jack Egatisky, MD Chairma, AAHHS Lawrece U. Haspell, DO Chairma, BHFA
Settig the cotext The iformatio i this report comes from HFAP surveyors ratigs of compliace with the 2016 Stadards ad their commets describig the ature of ay deficiecies foud. The data were collected durig osite surveys ad are segmeted by type: acute care hospitals, critical access hospitals (CAH), laboratories, ad ambulatory surgery ceters (ASC). Because the physical eviromet is costatly chagig ad the relevat stadards iclude o-goig moitorig ad maiteace that ofte is performed or oversee by a egieerig departmet, the high-deficiecy stadards for emergecy maagemet, life safety ad physical eviromet are idetified i their ow sectio of this report. This report icludes data collected from iitial ad reaccreditatio surveys oly. It does ot iclude focused surveys those that did ot iclude all applicable Stadards or those that were the result of a formal complait. The top areas of deficiecy with specific stadards idetified, represetative commets o the fidigs, ad suggestios for improvemet are preseted for each facility type as follows: Acute Care Hospitals...page 2 Critical Access Hospitals...page 8 Emergecy Maagemet...page 10 Physical Eviromet...page 12 Life Safety Code...page 15 Laboratories...page 18 Ambulatory Surgical Ceters...page 21 The cocludig sectio (page 25) lists additioal resources to support compliace. Note: the terms goverig board ad goverig body are used iterchageably throughout this documet. HFAP QUALITY REPORT 2017 1
Accreditatio Survey Fidigs by Facility Type Acute Care Hospitals: Top Areas of Deficiecy The table below begis with the chapter title from the HFAP maual, Accreditatio Stadards for Acute Care Hospitals, to idicate the broad area ecompassed by the frequetly cited deficiecy. The specific stadard(s) withi that chapter are listed with a high level overview of their essece or itet. Please ote that this is ot iteded to be a comprehesive review of stadards; review the laguage of the stadards ad the accompayig explaatios provided i the maual for additioal detail. Specific examples of surveyor commets whe scorig o-compliace are icluded uder Examples of Surveyor Fidigs ad below that are Tips for Improvemet that idetify areas ofte missed by acute care facilities that have bee rated ot compliat with the requiremet. Note: The most frequet deficiecy cited for hospitals is 11.00.01 Coditio of Participatio: Physical Eviromet. See page 12 for the stadards that most ofte cotributed to this deficiecy. Admiistratio Stadard 01.01.23 Cotractor Quality Moitorig The goverig body has resposibility to esure that services provided uder cotract are safe ad effective. I order to fulfill this resposibility, the hospital must commuicate the list ad scope of services the cotractors provide. This is doe through the QAPI program. A complete list of cotracted services is ot maitaied. List does ot iclude scope ad ature of service. No evidece of a evaluatio process for cotracted services. Cotractor s quality data is reviewed by the QAPI committee, but ot commuicated to the goverig board. Caot have a oe size fits all evaluatio form for all cotracted services. QAPI pla approved by the goverig board does ot iclude a mechaism to evaluate the quality of each cotracted service. The process (icludig frequecy) for evaluatig cotracted services icluded i the QAPI pla was ot approved by the goverig board. HFAP QUALITY REPORT 2017 2
Admiistratio Stadard 01.01.23 Cotractor Quality Moitorig cot. Maitai a comprehesive list of cotracted services icludig scope ad ature of service. Esure that the QAPI pla icludes how ad whe the quality of each cotracted service will be evaluated ad that the overall pla is approved by the goverig board aually. Whe developig a cotract for services, detail how the service will be evaluated, the frequecy of data collectio, ad the meas of submissio. After cotractor data is submitted to the QAPI committee, be sure that it is icluded i the report to the goverig board. Whe the goverig board reviews cotracted services evaluatios, the discussio ad approval must be memorialized i the miutes. Medical Staff Stadards 03.01.01 Medical Staff Bylaws; 03.04.03 UR Review Requiremets; 03.15.01 Ogoig Professioal Practice Evaluatio (OPPE) The hospital has a orgaized medical staff that operates uder bylaws approved by the goverig body. The medical staff is resposible to the board of trustees for the quality of medical care provided to patiets i the hospital uder the structure of medical staff goverace. The UR Pla does ot list all requiremets i stadard 03.04.03. Medical Staff bylaws did ot iclude quality measures or FPPE/OPPE process to justify gratig privileges. OPPE process ot implemeted. The Utilizatio Review Pla must provide for review for Medicare ad Medicaid patiets with respect to the medical ecessity of: (i) Admissios to the istitutio; (ii) The duratio of stays; (iii) Professioal services furished icludig, drugs ad biologicals. The Medical Staff bylaws defie the process of OPPE. HFAP QUALITY REPORT 2017 3
Medical Staff Stadards 03.01.01 Medical Staff Bylaws; 03.04.03 UR Review Requiremets; 03.15.01 Ogoig Professioal Practice Evaluatio (OPPE) cot. Medical Staff bylaws must iclude quality measures (for physicias ad o-physicia practitioers grated privileges), the OPPE pla, ad process. Use at least two admiistrative quality measures ad two cliical measures. The UR Pla icludes every item listed i the stadard ad the UR meetig miutes reflect review of these items. OPPE data is collected at least 3 times durig the 2 year appoitmet period. The medical staff has a process to evaluate low volume practitioers. The credetialig files reflect that OPPE data was reviewed ad cosidered at the time of reappoitmet. Ifectio Cotrol Stadard 07.01.01 - Ifectio Cotrol Officer, 07.01.02- Ifectio Prevetio A idividual is desigated as ICO ad i this role holds resposibility for developig, implemetig ad evaluatig measures goverig the idetificatio, ivestigatio, reportig, prevetio ad cotrol of ifectios ad commuicable diseases. The ICO develops a system for idetifyig, ivestigatig, reportig ad prevetig the spread of ifectios amog patiets ad persoel. Summaries of walkig rouds are ot documeted i the Ifectio Cotrol committee miutes. The operatig rooms had peetratios, rust o exit doors, door frames ad cabiets, chipped pait, isects i the leses of light fixtures ad divots i the operatig room doors. Had washig observatios revealed lapse i had hygiee before eterig a patiet room, prior to glovig, ad upo exitig a patiet room followig patiet cotact. Cliics ad outpatiet/off-site areas are ot icluded i ifectio cotrol plas. Air flow exchages i decotamiatio rooms are ot documeted ad/or do ot meet stadard rates ad/or are ot submitted to the IC committee. Decotamiatio rooms have iadequate separatio of clea ad dirty scopes. HFAP QUALITY REPORT 2017 4
Ifectio Cotrol Stadard 07.01.01 - Ifectio Cotrol Officer, 07.01.02 - Ifectio Prevetio cot. Iclude all areas of the facility i walkig rouds : ORs, decotamiatio rooms, cliics, outpatiet areas ad off-site facilities. Write summaries for review i the miutes of IC committee meetigs. Review had hygiee guidelies ad schedule educatio for staff/physicias. Postig scorecards by departmet ca be a effective meas of improvig compliace. Secret Shoppers ca be used for surveillace of compliace with hospital policy. Observe ad evaluate the process for cleaig scopes to esure adequate space ad separatio of clea ad dirty areas. Collect air exchage data for submissio to the IC committee. Esure that more tha oe staff member is traied i sterilizatio ad disifectio processes. Quality Stadard 12.00.01 Data Collectio & Aalysis: Program Scope; 12.00.03 Patiet Safety, Medical Errors & Adverse Evets; 12.00.05 Executive Resposibilities The QAPI program must be comprehesive, hospital wide ad data drive. No evidece of review of patiet safety evets. No evaluatio of cotracted services. The pharmacy s Medicatio Use Evaluatio was ot submitted to the quality committee. Implemet a database for trackig evets such as medicatio errors (icludig missed medicatios), wrog site surgery, etc. Review data with those directly ivolved. Moitor effectiveess of corrective actio. Iclude expectatios for safety i the QAPI pla. Maitai curret list of cotracted services ad esure that each service moitors quality idicators. HFAP QUALITY REPORT 2017 5
Patiet Rights Stadard 15.01.03 - Patiet grievaces; 15.01.04 Goverig Body Resposibility for the Grievace Process; 15.01.05 Timely Referrals; 15.02.00 - Restrait or Seclusio; 15.02.10 Orders for Restrait or Seclusio Patiets basic rights are idetified icludig a process for commuicatig ad resolvig grievaces, esurig patiet safety, ad elimiatig the iappropriate use of restrait or seclusio. Grievace policy was ot approved by the Goverig Board. Grievace policy omits how patiets are iformed of the grievace process, defiitio of complait vs. grievace, time frame for resolutio. Respose letter to grievace was set beyod 7 days expectatio of the stadard. Grievace respose letter lacks steps take to ivestigate, decisios made, completio date ad/or cotact perso. Grievace files lacked evidece of ivestigatio. Hospital was uable to demostrate how complaits are resolved. Medical record lacked documetatio of least restrictive itervetio used. Physicia restrait orders used the term per protocol without supportig detail (how, whe, itervals, etc.) describig protocol. Policy permitted trial release. PRN orders for use of restraits are prohibited. Gaps i moitorig based o policy requiremets. No evidece of physicia traiig. Make sure the grievace policy addresses all required items i the stadard as well as how the grievace process must be implemeted. Follow the HFAP accreditatio requiremets i the explaatio colum of the maual that idetifies compoets of the policy, the medical record documetatio required, resposibilities of each staff member. Esure the restraits policy icludes all required compoets of the stadard. Schedule ad coduct periodic audits of patiets i restraits or of closed medical records to cofirm that all policy requiremets are followed ad appropriately documeted. HFAP QUALITY REPORT 2017 6
Nursig Services 16.01.01 Preparatio ad Admiistratio of Drugs There must be a safe ad effective method for admiistratio of medicatios with policies ad procedures approved by the medical staff. Staff must be educated ad competet i implemetig protocols. No evidece of ICU RN staff traiig ad competecy assessmet for the admiistratio of IV Propofol. Idetify high risk medicatios. Provide educatio ad competecy assessmet for high-risk medicatio protocols. Surgical Services Stadard 30.00.10 History & Physical; 30.01.00 Coditio: Medical Leadership for Aesthesia Services; 30.01.05 Pre-aesthesia Evaluatio; 30.01.07 Postaesthesia Evaluatio A complete H&P is completed o more tha 30 days before or 24 hours after admissio, except i emergecies. A physicia who has privileges ad qualificatios is appoited to direct aesthesia services i all areas of the hospital providig aesthesia. Evaluatios are performed for patiets udergoig geeral, regioal or moitored aesthesia prior to ad withi 48 hours after receivig aesthesia. Medical record icludes H&P older tha 30 days without a update. No documetatio of appoited director of aesthesia services. No evidece of the evaluatio of quality of aesthesia service i the hospital QAPI program. A physicia is appoited Medical Director of Aesthesia ad the appoitmet icludes writte documetatio. Iclude the appoitmet i orgaizatioal chart for aesthesia. Writte qualificatios ad eligibility of the Medical Director of Aesthesia are approved by the medical staff ad goverig body. Iclude the resposibility for moitorig the quality ad appropriateess of aesthesia services i the Medical Director s job descriptio. HFAP QUALITY REPORT 2017 7
Critical Access Hospitals (CAH): Top Areas of Deficiecy The table below begis with the chapter title from the HFAP maual, Accreditatio Stadards for Critical Access Hospitals, to idicate the broad area ecompassed by the frequetly cited deficiecy. The specific stadard(s) withi that chapter are listed with a high level overview of their essece or itet. Please ote that this is ot iteded to be a comprehesive review of stadards; review the laguage of the stadards ad the accompayig explaatio provided i the maual for additioal detail. Specific examples of surveyor commets whe scorig o-compliace are icluded uder Examples of Surveyor Fidigs ad below that are Tips for Improvemet that idetify areas ofte missed by CAHs that have bee rated ot compliat with the requiremet. Note: The most frequet deficiecy cited for CAHs is 03.00.01 Coditio of Participatio: Physical Eviromet. See page 12 for the stadards that cotributed most ofte to this deficiecy. Staffig ad Staff Resposibilities Stadard 05.00.09 Resposibilities of the MD or DO: Reviews ad Sigs Medical Records. All ipatiet records are reviewed ad siged by a CAH MD/DO eve whe care was maaged by a o-physicia practitioer. Medical records siged by allied health staff are ot siged off by the medical staff. Develop a process for medical records review ad co-sigig. Provisio of Services Stadard 06.00.03 Policy Scope; 06.01.00 Medicatio Storage ad Admiistratio The CAH s writte policies describe the rage of services provided o-site ad off-site, ad furished by CAH staff or by cotractors. The scope of services documet does ot address all departmets or services. Medicatios are foud usecured i outpatiet settigs. Policies iclude rules for storage, hadlig, dispesig, ad admiistratio of drugs ad biologicals. HFAP QUALITY REPORT 2017 8
Provisio of Services Stadard 06.00.03 Policy Scope; 06.01.00 Medicatio Storage ad Admiistratio cot. Esure the scope of service documet lists every departmet ad service, icludig the laboratory ad ay services furished by a cotractor. The pharmacy is resposible for all medicatios at all ipatiet ad outpatiet locatios. Medicatios must be secure i all areas. Provisio of Services Stadard 07.00.04 Record Cotet Requiremets The medical record icludes evidece of iformed coset for procedures, medical history, progress otes ad documetatio that justifies admissio, supports the diagosis, describes the patiet s respose to treatmet ad provides a discharge summary. Medical record lacks tests results. Medical record lacks discharge summary. Audit medical records periodically to esure all patiet data is oted. Review the stadard for the list of items that should be icluded i the record, amog them: diagosis, orders, evaluatios, treatmets, test results, care plas, cosets, itervetios, discharge summary. Iclude cliical evaluatio iformatio obtaied from post-discharge follow-up telephoe calls: care provided ad the patiet s respose to treatmets ad itervetios. HFAP QUALITY REPORT 2017 9
Emergecy Maagemet Stadards: Top Deficiecies The deficiecy fidigs below are applicable to both acute care hospitals ad CAHs. The first idetifier comes from Accreditatio Stadards for Acute Care Hospitals ad the secod from Accreditatio Stadards for Critical Access Hospitals. The stadards are listed i descedig order of frequecy as deficiecies for acute care hospitals with 09.01.12 appearig as a deficiecy i 32% of surveys ad 09.01.08 appearig as deficiecy i 7% of surveys. All of the deficiecies reflect missig elemets of a Emergecy Operatios Pla (EOP). Tip: Make your EOP as comprehesive as possible. Stadard umber ad topic Deficiecy Tip for improvemet 09.01.12/17.01.12 Busiess Cotiuity No writte busiess cotiuity pla. Develop strategies for how the orgaizatio will recover from a emergecy evet. 09.01.02/17.01.02 Emergecy Supplies The emergecy supply pla was icomplete. There was o ivetory of emergecy supplies that would be used at the start of a emergecy evet. A ivetory of the emergecy supplies was ot coducted semiaually. Supply of emergecy water was ot kept o site. Defie the list of emergecy supplies. Review at least semiaually that the supplies o had ivetory is complete ad segregated from items for ogoig use. 09.01.01/17.01.01 Emergecy Safety & Security The safety ad security pla was icomplete. The Emergecy Operatios Pla (EOP) does ot provide for the security of supplies. Iclude the security of emergecy supplies i the EOP. 09.01.05.17.01.05 Emergecy Persoel Protective Equipmet The EOP does ot address PPE. Accout for PPE i the EOP. HFAP QUALITY REPORT 2017 10
Stadard umber ad topic Deficiecy Tip for improvemet 09.01.04/17.01.04 Emergecy Decotamiatio The EOP does ot provide for chemical, biological, ad radioactive decotamiatio. There was o traiig provided for the decotamiatio equipmet. The emergecy decotamiatio room was used for storage. Develop a traiig program for use of the decotamiatio equipmet that also idetifies who (by role) should be traied. Esure the decotamiatio facilities are ready for immediate use. 09.01.09/17.01.09 Emergecy Triage The EOP does ot iclude triagig of victims. Eve if you use the same triagig procedures for a emergecy as you would for ormal busiess, it should be spelled out i the EOP. 09.01.03/17.01.03 Emergecy Utilities The EOP does ot provide for emergecy utilities. Develop writte agreemets with vedors to provide specific utilities ad supplies durig a emergecy evet. 09.01.06 Emergecy Nutritioal Services The EOP does ot provide for utritioal eeds. Review the utritioal services portio of the EOP, ad documet all of the alterate methods of feedig patiets ad staff durig a emergecy. 09.01.11/17.01.11 Voluteer Maagemet The EOP does ot address voluteers. Use the same process for credetialig voluteers durig a emergecy evet as you would to credetial ew professioal staff durig ormal busiess. Cosider your ability to implemet a credetialig process durig a emergecy ad cosider writig a policy that states that the orgaizatio will refuse all professioal voluteer help. 09.01.08/17.01.08 Icidet Commad Ceter The EOP does ot iclude drawigs for the icidet commad ceter. The EOP does ot idetify the locatio of the icidet commad ceter. Ivetory all equipmet that will be used i the Icidet Commad Ceter. Documet where that equipmet is stored before a emergecy evet. Create drawigs idetifyig where that equipmet eeds to be setup whe the Icidet Commad Ceter is lauched. HFAP QUALITY REPORT 2017 11
Physical Eviromet Stadards: Areas of Deficiecy The deficiecy fidigs below are applicable to both acute care hospitals ad CAHs. The first idetifier comes from Accreditatio Stadards for Acute Care Hospitals ad the secod from Accreditatio Stadards for Critical Access Hospitals. The stadards are listed i descedig order of frequecy as deficiecies for acute care hospitals with 11.01.10 appearig as a deficiecy i 33% of surveys ad 11.01.01 appearig as deficiecy i 6% of surveys. Stadard umber ad topic Deficiecy Tip for improvemet 11.01.10/03.01.02 Eyewash Statios Eyewash statios are ot tested o a weekly basis. Eyewash statios istalled do ot meet ANSI Z358.1-2014 requiremets. Eyewash statios are ot located withi 55 feet of hazardous materials. Purchase a copy of the ANSI Z358.1-2014 stadard o eyewash statios ad comply with the istallatio ad testig requiremets. 11.01.02/03.01.02 Buildig Safety Ligature risks i behavioral health uit without a risk assessmet. Rooftop exhaust fas for isolatio areas ot marked with bio-hazard symbols. Dirty ceilig tiles, dirty vets ad cracked walls i exam room. Trash compactor has key left i cotroller. Coduct frequet ispectios of behavioral health uits lookig for potetial ligature risks. 11.04.02/03.04.02 Fire Drills Quarterly Off-site locatios did ot coduct drills. Fire drills were ot coducted o all shifts every quarter Schedule fire drills oce per shift per quarter. Stagger the start times for fire drills o the same shift each quarter, by 2-hours. HFAP QUALITY REPORT 2017 12
Stadard umber ad topic Deficiecy Tip for improvemet 11.05.01/03.05.01 Medical Equipmet & Systems Maiteace Blaket warmers are ot icluded i the medical equipmet prevetative maiteace program. No prevetative maiteace records o medical equipmet for previous year. No risk assessmet for medical equipmet i Alterate Equipmet Maagemet (AEM) program. No aual evaluatio of AEM program. Past due ispectios o medical equipmet. It is o loger acceptable that oly 95% of the medical equipmet be tested. CMS ow requires that 100% of the medical equipmet be properly tested. 11.07.03/03.07.03 Vetilatio, Light & Temperature Cotrols Multiple rooms had bee idetified as ot havig proper air pressure relatioships but o evidece of corrective actio. No cosistet vetilatio i clea utility rooms. Positive air pressure relatioship ot maitaied i Cetral Sterile. Develop a program whereby you ispect every air-pressure relatioship room weekly, checkig for proper air-pressure relatioships (positive or egative) ad makig correctios as eeded. 11.00.02/03.00.02 Required Plas ad Performace Stadards The facility did ot preset oe or more required maagemet plas. Maagemet plas are lowhagig fruit: Either you have them or you do t. Esure you have a maagemet pla for every disciplie required. 11.02.04/ Security Sesitive Areas The facility did ot idetify security sesitive areas. Security sesitive areas idetified but o pla for how the orgaizatio will secure them. Idetifyig security sesitive areas is as easy as sittig dow ad discussig it with a group of stakeholders. 11.03.06/03.03.06 Hazardous Areas Routie Moitorig The facility does ot have ay evidece of moitorig waste aesthesia gas. The facility does ot have ay evidece of moitorig ethyleeoxide gas. Develop a program of moitorig hazardous areas. HFAP QUALITY REPORT 2017 13
Stadard umber ad topic Deficiecy Tip for improvemet 11.06.09/03.06.04 Plat Equipmet & Systems Maiteace Not all plat equipmet was icluded i the prevetative maiteace program. Plat equipmet idetified as beig o the AEM program did ot have a risk assessmet coducted. AEM program for plat equipmet did ot have a aual evaluatio. A AEM program is ot for everyoe it s ot to be used without serious ad careful cosideratios of all of the required actios. 11.01.01/03.01.01 Periodic Moitorig for Safety Issues Not all patiet-care areas were moitored twice per year. Offsite locatios that are patiet care areas were ot moitored. Deficiecies idetified durig the routie moitorig were ot resolved. Develop a program of moitorig all offsite locatios. HFAP QUALITY REPORT 2017 14
Life Safety Areas of Deficiecy The deficiecy fidigs below are applicable to acute care hospitals, critical access hospitals, ad frequetly, to ambulatory surgical ceters. The first idetifier comes from Accreditatio Stadards for Acute Care Hospitals ad the secod from Accreditatio Stadards for Critical Access Hospitals. Whe a third stadard is listed, it is from Accreditatio Stadards for Ambulatory Surgical Ceters. The absece of a stadard specific to ASC settigs does ot mea that the stadard is ot relevat; it may be a regulatio icluded i NFPA 99 or 101, which serve as additioal refereces for life safety requiremets i ASCs. The stadards are listed i descedig order of the frequecy of citatio for acute care hospitals. Fire alarm system istallatio is cited i 78% of surveys; ceiligs i 49%. Stadard umber ad topic Deficiecy Tip for improvemet 13.02.01/14.02.01/ 05.03.07 Fire Alarm Systems Istallatio Smoke detectors are mouted too close to air diffusers. Smoke detectors are mouted more tha 12 iches below a deck. Read ad uderstad the NFPA 72-2010 fire alarm istallatio requiremets. Discuss fire alarm system istallatio issues with your fire alarm cotractor lear from them. Coduct frequet ispectios of the facility. 13.01.05/14.01.05/ 05.03.03, 04 Meas of Egress Sigage Exit sigs are ot istalled where the path of egress is ot readily apparet. No Exit sigs are ot istalled where a door may be cofused as a exit. Do your ow self-ispectio of each path of egress Is the egress path marked with Exit sigs? 13.02.02/14.02.02/ 05.03.07 Fire Alarm Systems Testig Not all of the devices coected to the fire alarm system are actually tested. No device ivetory idetifyig a Pass or Fail decisio. Report ot siged by the techicia performig the service. Report does ot referece the correct NFPA stadard or editio. Copy Table 14.4.5 from NFPA 72-2010 ad make sure your testig cotractor tests every compoet listed that you have i your system. Use HFAP stadard 13.00.07 as a template to esure the report has all of the required iformatio. HFAP QUALITY REPORT 2017 15
Stadard umber ad topic Deficiecy Tip for improvemet 13.05.09/14.05.09 Utility Systems Juctio boxes above the ceilig do ot have covers. Access to electrical paels ad cotrols is obstructed. Do your ow frequet ispectios above the ceilig, ad i electrical rooms, lookig for items of ocompliace. 13.00.05/14.00.05 Facility Demographic Report (FDR) The FDR is ot completed properly questios left uaswered. Costructio type is ot listed i NFPA veracular. Occupacy classificatio is ot listed i NFPA veracular. Esure the perso who completes the FDR is qualified to provide the aswers. S/he must have a workig kowledge of the hospital facility, ad of the NFPA codes ad stadards. 13.01.02/14.01.02/ 05.03.06 Door Locks Doors i the path of egress are locked ad do ot comply with the Life Safety Code. Access-cotrol locks do ot have the motio sesor istalled o the egress side. Delayed egress locks are istalled i buildigs that are ot fully protected with spriklers. Iappropriate use of Cliical Needs locks. Mistake belief that security overrides the eed for safety. Read ad uderstad sectio 19.2.2.2.4 of the 2012 Life Safety Code regardig the exceptios that permit certai doors to be locked i the path of egress i a hospital. Life Safety compliace overrides security. Do ot allow security people to istall locks o doors that do ot comply with the LSC. 13.04.01/14.04.01 Fire Rated Barriers Usealed peetratios i fire rated barriers. Top of fire walls do ot always exted to the deck above. Patches istalled o fire-rated barriers that do ot comply with the UL listig. Establish a Above Ceilig Permit program whereby every cotractor who works above the ceilig must receive a permit from Egieerig. Egieerig the tracks all work ad holds that cotractor resposible for fillig all usealed peetratios i rated barriers. Coduct frequet ispectios above ceilig o rated walls, lookig for usealed peetratios ad improperly applied patches over holes. HFAP QUALITY REPORT 2017 16
Stadard umber ad topic Deficiecy Tip for improvemet 13.06.04/14.06.04 Life Safety Drawigs Drawigs do ot iclude all of the required iformatio. Drawigs do ot accurately reflect as-built coditios. Cotract with a architect who has experiece with healthcare ad the Life Safety Code to create workig drawigs of your rated wall system. 13.04.07/14.04.07 Fire Rated Door Assemblies Label idetifyig the fire-ratig is missig or paited over. Door ad frame are ot fire-rated. Coduct aual (or more frequet if ecessary) ispectios of all fire-rated door assemblies. 13.04.09/14.04.09 Ceiligs Holes ad gaps i ceilig are larger tha 1/8 ich. Missig ceilig tiles. Replace all missig or damaged ceilig tiles as soo as they are discovered. Do ot let a day pass without all the ceilig tiles i place. Coduct frequet ispectios, ad add ceiligs to the list of thigs to ispect. HFAP QUALITY REPORT 2017 17
Laboratories The fidigs i this sectio come from HFAP bieial laboratory surveys that lead to accreditatio with deemed status for CLIA regulatios. These stadards are distict from the review of laboratory services that takes place as a compoet of a survey for a acute care hospital or critical access hospital which are based o Medicare Coditios of Participatio. Laboratory High-Deficiecy Fidigs 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 06.01.07 06.01.16 06.02.01 06.04.00 06.04.01 06.06.01 06.08.01 07.06.01 07.07.02 07.08.01 07.09.01 07.11.05 The Laboratory deficiecies see i 2016 surveys clustered primarily ito two groups. The first group is from chapter 6: Aalytic Systems. These regulatios require laboratories to follow test system maufacturer s istructio for performig the testig. This meas the laboratory must follow ad perform the maufacturer s package isert istructios as approved or cleared by the FDA. For stadard 06.01.07, most surveyor commets refereced a discrepacy betwee maufacturer s istructios ad actual laboratory practice primarily related to lapses i quality cotrol for specific tests. Tips for improvemet Each test procedure should iclude quality cotrol ad frequecy of use. At least aually, quality cotrol procedures should be audited to be sure they reflect actual practice. The procedures must be tailored to reflect idividual lab processes while adherig to maufacturer s istructios. HFAP QUALITY REPORT 2017 18
Deficiecies cited for stadard 06.01.16 relate to missig documetatio; specifically, mauals that icluded updates ad revisios that had ot bee approved i writig by the Laboratory Director. Tips for improvemet Coduct a periodic review of all mauals to esure that procedures reflect curret practice. Updated procedures should be dated ad siged by the Director. Outdated procedures should be removed from the maual, dated with the reaso for removal oted, ad retaied i a outdated procedure file. I the evet of a chage i Laboratory Director, a timelie for review ad sig-off o all procedures should be established with completio scheduled for o loger tha three to six moths from the date the ew Director assumed resposibility for the lab. Stadard 06.02.01 requires the laboratory to defie criteria for water quality, temperature, humidity ad electrical fluctuatios/iterruptios. Surveyors cited missig policies ad failure to log documetatio that policies were followed. Tips for improvemet The procedure that defies water types used must also specify what water checks are doe ad i what time frame. Review istrumet mauals ad package iserts for miimum/maximum temperature ad humidity. A daily log may be helpful but if the area is ot moitored over a weeked/holiday period, a hi-low thermometer may be used. I the evet that the temperature/humidity is outside of the maufacturer s rage, documetatio of corrective actio is required. Be aware that certified thermometers/hygrometers have expiratio dates ad must be re-certified or replaced. Stadard 06.04.00 ad 06.04.01 require that maiteace ad fuctio checks respectively, as defied by the maufacturer ad at a specified frequecy, are required for equipmet, istrumets, ad test systems. Most deficiecies result from a discrepacy betwee the maiteace frequecy idetified i the lab policy ad the actual maiteace performed. Tips for improvemet At miimum, the lab must perform what is recommeded by the maufacturer. Review package iserts ad istrumet mauals. Set up a schedule for maiteace ad fuctio checks with log sheets. Empower staff to share i resposibility for completio of maiteace. Do t forget to iclude the daily maiteace of microscopes ad peripheral equipmet i the pla ad documetatio. Documet review of log sheets (at least mothly) by lead staff or supervisor to esure that all fuctio tests have bee performed. HFAP QUALITY REPORT 2017 19
Stadard 06.06.01 is focused o quality cotrol that meets or exceeds CLIA regulatory requiremets. Tips for improvemet Laboratories must perform two levels of exteral cotrols o each test system for each day of testig ad follow all specialty/subspecialty requiremets for owaived tests OR develop a Idividualized Quality Cotrol Pla (IQCP) to customize the quality cotrol procedures for a test system. CMS ad CDC have developed a step by step maual Developig a IQCP, that is available for dowload at www.cdc.gov/clia/documets/iqcp%20loyout.pdf. Additioally CMS has three brochures to assist laboratories with IQCP. Brochure #11 - CLIA Idividualized Quality Cotrol Pla Itroductio (IQCP) Brochure #12 - CLIA IQCP, Cosideratios Whe Decidig to Develop a IQCP Brochure #13 - CLIA IQCP, What is a IQCP? The free brochures are available at: www.cms.gov/regulatios-ad-guidace/legislatio/clia/clia_brochures.html. 06.08.01 cocers istrumet correlatio studies to esure that tests usig differet methodologies, istrumets, or performed at differet sites are evaluated to defie the relatioship across results. Deficiecies here are the result of failure to coduct the comparisos. Tips for improvemet Use a caledar remider system to schedule comparisos that must be made every six moths. Idicate the acceptable rage of differece whe defiig the procedure. Periodically audit what tests are performed o what istrumets. Determie if there is a maual back-up method. Compare the back-up result to the primary istrumet if it is to be used i case of a istrumet failure. Elimiate istrumetatio that is o loger used i either primary or back-up status. Test procedures should idicate the back-up steps i the evet of a istrumet failure. The secod cluster of high deficiecy citatios comes from chapter 7: Proficiecy Testig. For proficiecy testig (PT), failure to attai a score of at least 80% of acceptable resposes for each aalyte i each testig evet is cosidered usatisfactory aalyte performace for the testig evet. Surveyors oted scores ragig from 0% to 60% for a rage of aalytes used i testig for geeral immuology (07.06.01), routie chemistry (07.07.02), edocriology (07.08.01), toxicology (07.09.01), ad hematology (07.11.05). Tips for improvemet Clerical errors play a big role i PT deficiecies. Have a system i place that requires a thorough review of all PT results before they are submitted to the PT vedor. Use o-lie submissio if available rather tha faxig. Look for trasposed umbers. Check that the test reportig uits are the same as those of the PT vedor. Make sure that the codes etered for test istrumetatio are correct. Ivestigate all 80% results to rule out potetial techical problems that could lead to future PT failures. HFAP QUALITY REPORT 2017 20
Ambulatory Surgery Ceters Goverig Body Maagemet Stadard 01.00.02 Goverig Body ad Maagemet The ASC has a desigated goverig body with direct oversight of the Quality Assessmet Performace Improvemet (QAPI) program. the quality of the services provided. the safety of the eviromet. The developmet ad maiteace of a disaster preparedess pla. The policy defiig the operatio of the ASC did ot reflect actual services provided. No performace measures were idetified to moitor cotracted services. The Emergecy Operatios Pla was outdated. No curret trasfer agreemet with a hospital. No policy for the scope ad timeframe for completig a H&P. No iitial credetialig for physicias. No credetialig ad privilegig structure i place. No quality iformatio available for review for physicias prior to appoitmet. No defied job resposibilities for departmet maagers. Develop a writte ASC scope of services documet which icludes the populatio served with actio plas defied if a patiet falls outside that scope. Follow the ASA Physical Status Classificatio System for ASC risk. Create checklists to esure that the goverig body reviews all areas of service at least aually. Make sure that meetig miutes reflect review ad approval of each area of resposibility. HFAP QUALITY REPORT 2017 21
Surgical Services 03.00.02 Surgical Services Performed Safely Oly those procedures defied withi the orgaizatio s scope of services are performed by qualified physicias who have bee credetialed ad privileged. All phases of the procedure meet acceptable stadards of practice. Procedures performed by a physicia without privileges. CRNA had expired credetials ad performed aesthesia services. No RN supervisio of LVN fuctio. The ASC has writte policies ad procedures which referece atioallyaccepted guidelies. The goverig body grats privileges based o writte qualificatios for specific services offered withi the ASC. Quality Assessmet Performace Improvemet Stadard 04.00.02 Program Scope; 04.00.10 Performace Improvemet Projects; 04.00.11-04.00.12 Goverig Body Resposibilities The ASC demostrates a focus o cotiuous quality improvemet through a orgaized, ogoig program of quality assessmet ad improvemet. The program is eacted through a umber of distict projects that reflect the scope ad complexity of the ASC s services. The ASC maitais records of its projects that iclude documetatio of the purpose, the data collectio, ad the results. The goverig body is ultimately resposible for the QAPI program. No aual quality report. No educatio o QAPI facility-wide. No quality idicators for cotracted services. No aual QAPI pla approval by the QAPI committee or the goverig body. Peer review activity ad/or patiet survey data ot reviewed by the QAPI committee as required. No ratioale for selected QAPI projects. Quality Maager had o quality traiig. Esure that the desigated quality maager has resources for traiig. The goverig body allows sufficiet time ad staff to perform quality activities. Discussio of quality issues is reflected i goverig body meetig miutes. HFAP QUALITY REPORT 2017 22
Medical Staff 06.00.01 - Medical Staff Membership ad Cliical Privileges; 06.00.03 - Reappraisals The orgaizatio of the medical staff ad the gratig of privileges is the resposibility of the goverig body. Procedures performed by physicia were ot o the list of privileges grated by the goverig body. CRNA had expired privileges. CRNA had expired ACLS ad BLS certificatio Review ad amed the Scope of Procedures/Delieatio of Privileges at least every two years ad prior to physicia reappoitmet. Create a schedule for reappraisal of medical staff ad o-physicia practitioers that require privilegig at least every 2 years. Ifectio Cotrol 12.00.01 Ifectio Cotrol The ASC s ifectio cotrol program provides a saitary eviromet for surgical services based o atioally-recogized ifectio cotrol guidelies. The ASC lacks a ifectio cotrol program/pla. The ifectio cotrol pla is ot based o a risk assessmet of the geographic area or patiet populatio served. The ASC uses a hospital-based IC pla ot specific to the facility. No traied ad qualified perso desigated to oversee the IC program. Desigate a qualified perso to develop ad oversee the ifectio cotrol program. Traiig ca be via o-lie modules or cofereces. Make resource refereces available; use part-time staff or a cosultat to assist i the IC program. Provide i-services ad orietatio traiig to all ASC staff. Review ad implemet atioally-recogized ifectio cotrol guidelies such as CDC, APIC, AORN, HICPAC, etc., ad iclude with policy ad procedures. ASCs ca cotact a hospital ICP to provide directio or support. Cotact the local DPH or CDC to idetify IC risks to your areas. HFAP QUALITY REPORT 2017 23
Patiet Admissio, Assessmet, ad Discharge 13.00.02 Admissio ad Presurgical Assessmet; 13.00.03 Admittig History & Physical Update A comprehesive H&P is iteded to determie if there is aythig i the patiet s overall coditio that would affect the plaed surgery. It must be performed ad documeted o more tha 30 days before the scheduled surgery. Medical record lacks a H&P completed withi 30 days. Medical record lacks a presurgical assessmet completed by a physicia to evaluate the risk prior to procedure ad aesthesia. Upo admissio to the ASC, a presurgical assessmet must be performed by a physicia to evaluate the risk of the aesthesia ad the procedure. Schedule regular review of medical records to determie compliace. HFAP QUALITY REPORT 2017 24
Success through educatio. HFAP offers support ad resources. Preparig for ad maitaiig accreditatio is a complex task. The requiremets are rigorous because they are iteded to address everythig with a potetial impact o patiet care. We ll help you avigate the shiftig focus from the big picture of where you wat to go, to the details of how to get there. Notificatio Services Request a subscriptio to HFAP s distributio of CMS S&C letters. We summarize the essece of the chage, what it meas for facilities, ad iclude a copy of the actual documet from CMS. E-mail ifo@hfap.org to be added to the distributio list. Webiars Aual webiars coverig core topics are available for each HFAP accreditatio program: acute care hospitals, CAHs, laboratories, ad ASCs. Topics rage from Top 10 Deficiecies ad How to submit Waivers ad Equivalecies to What Executives should kow about Credetialig ad Privilegig ad IQCP for Laboratories. The library of educatioal programs is available o-demad at https://hfap.org/resources/evets ad ew topics are added aually. Cotact ifo@hfap.org to request otificatio of upcomig presetatios. Semiars HFAP Bootcamp provides itesive traiig o emergecy maagemet, physical eviromet ad life safety code for healthcare egieers. I 2018, HFAP Bootcamp will be held i Des Plaies, IL (ear O Hare airport) i May. Cotact ifo@hfap.org to receive a aoucemet. HFAP Prep provides a iteractive overview of the curret stadards with tracks for acute care hospitals, CAHs, ad ASCs. I 2018, this coferece will be held i Des Plaies, IL (ear O Hare airport) i September. Cotact ifo@hfap.org to receive a aoucemet. HFAP O-site brigs HFAP resources to your facility. This customized educatioal optio ca focus o your facility s uique eeds, or allow you to host a day of educatio for your commuity. Cotact ifo@hfap.org to discuss your eeds. HFAP Speaker s Bureau is a resource for professioal cofereces ad meetigs. HFAP s expert staff ad surveyors ca speak o topics covered by ay of our accreditatio or certificatio programs. Cotact ifo@hfap.org to discuss optios. Certificatio Programs Educatio is also available for HFAP certificatio programs for: Stroke Ceters (programs targeted to Stroke Ready, Primary Stroke, ad Comprehesive Stroke Ceters) Woud Care Laser/Lithotripsy (programs targeted to basic, advaced ad iovative ifrastructures) With additioal programs for compoudig pharmacies ad joit replacemet scheduled to begi i 2018. HFAP QUALITY REPORT 2017 25
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