Accreditation quality review shows common deficiencies in hospitals, ambulatory surgery centers and labs
For acute care and critical access hospitals, infection control was a significant focus in 2020 as standards were updated.
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Hospitals getting accreditation review and the process itself were impacted by COVID-19 in 2020, a recently-released annual report shows.
The Accreditation Commission for Health Care (ACHC) has identified deficiencies in acute care and critical access hospitals, ambulatory surgery centers and laboratories.
"We didn't know what we'd see this year, because of COVID-19 having an impact," said Deanna Scatena, associate program director of Acute Care Hospital/Critical Access Hospital for ACHC. "In some instances, we can determine a direct correlation imposed by the public health emergency and in other instances, we were pleasantly surprised. Most findings are not repeat deficiencies."
Another positive result, she said, was the low volume of deficiencies related to emergency management.
"Not all impacts of the pandemic have been negative," said José Domingos, president and CEO of ACHC, writing in the report. "Change is hard, but the drive and resourcefulness of organizations committed to meeting the needs of their communities led to innovation and rapid adoption of new ideas. For example, telehealth is a sleeping giant awakened."
The ACHC expects to soon offer telehealth certification.
THE FINDINGS
Chief findings from the 2021 HFAP Review from ACHC show that for acute care and critical access hospitals, infection control was a significant focus in 2020 as standards were updated, Scatena said.
At 20% or more of critical access hospitals, 22 clinical and administrative standards were cited. Of the five standards cited most frequently, four were related to infection control, the pandemic being an important contributor.
In 20% or more of acute care hospitals surveyed, 39 clinical and administrative standards were cited as deficiencies. Areas of concern included risk mitigation, environmental surveillance and contact-isolation signage.
Of the 19 top deficiencies for ambulatory surgery centers, five stood out in terms of frequency, and, of these, three centered on documentation. But overall, survey findings indicated that patients received high-quality care, the report said.
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.
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.
Clinical laboratories managed high testing volumes, the demand for rapid turnaround time and supply chain constraints related to the pandemic while still managing the "normal" process of diagnostic testing in support of clinical, infection control and public health decisions, the report said.
However, 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.
WHY THIS MATTERS
The accreditation process is not mandatory, but many providers use accreditation as third-party validation of quality and as a way to recertify eligibility for Medicare and Medicaid reimbursement.
ACHC holds "deemed status," meaning it conducts surveys on behalf of the Centers for Medicare and Medicaid Services.
To maintain this deeming authority, ACHC Standards reflect CMS regulations and are periodically reviewed by CMS, Scatena said. "It provides that extra layer of accreditation and factors in CMS regulations."
When ACHC auditors go in, they don't expect to find 100% compliance. What is expected is that they generate a plan of corrections, she said.
The accrediting organizations such as ACHC do not make the reports public, but there may be instances where a state may step in and make them public. CMS did offer some waivers to provide flexibility during 2020 because of the pandemic.
"Over the past 18 months, hospital materials management teams sourced against a shortage of PPE, nursing leadership reassigned staff to address illness or furloughs, normally busy ASCs cancelled cases and closed, critical access hospitals coped with patient surges, and laboratories managed new testing protocols and extraordinary volume under Emergency Use Authorizations," Domingos said in the report. "These, and a myriad other issues, demonstrate that no area of healthcare escaped the impact of the COVID-19 public health emergency."
The accreditation programs also were affected, he said. Survey activity was interrupted from mid-March to June 2020 during the height of state-mandated lockdowns, when travel was restricted and facilities were stretched thin, he said. During this period, data was collected through surveys.
THE LARGER TREND
HFAP merged with the ACHC in 2020. The merger means ACHC is now a single-source accreditor, Scatena said.
The annual publication is designed to help healthcare organizations learn from their peers, overcome common challenges and promote continuous quality improvement.
"We know this report adds value as a quality improvement process," Scatena said.
Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com
