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Q&A: 2019 quality review highlights ligature risk, IC, fire safety


August 1, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

Ligature risk, building safety problems, and infection control were among the top problems identified by Healthcare Facilities Accreditation Program (HFAP) surveyors last year, according to the recently published 2019 HFAP Quality Review.

HFAP and other accrediting organizations (AO) have been under pressure from CMS to do a better job of identifying Life Safety Code® (LSC), environment of care, and infection control problems. The concerns have been made public in reports to Congress reviewing the work of AOs (IJC 3/19/18) and in memos to state survey offices emphasizing ligature risks and other environmental hazards patients can use to harm themselves.

The HFAP Quality Review calls on hospitals and other healthcare organizations to work more closely with HFAP staff before and after survey to concentrate on overall quality improvement. In addition, it calls for them to work on the specifics of the HFAP standards most often cited by surveyors”.

The accreditor also wants organizations to better explain themselves during surveys.

“HFAP surveyors are trained to be opened to a variety of ways of achieving compliance,” said Gary Ley, board chairman of HFAP’s parent company, the Accreditation Association for Hospitals/Health Systems (AAHHS), in the report’s foreword. “Your job is to be an advocate for your organization’s approach. The more effectively you can paint that picture for your surveyor/survey team, the more they’ll have to offer with regard to meaningful educational support.”

The two standards posing the most problems for HFAP-accredited hospitals in 2018 were 11.00.01 on the Physical Environment, and 07.01.02 on Infection Prevention. For each of those standards, 68% of surveyed acute care hospitals were cited for deficiencies.

Physical environment

Standard 11.00.01 crosswalks with Condition of Participation (CoP) §482.41 on the Physical Environment, and requires a hospital to “be constructed, arranged, and maintained to ensure the safety of the patient,” among other things.

Like many of HFAP’s standards, the language largely mirrors the CoP—“The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.” And deficiencies are considered condition-level, meaning they trigger an automatic second survey from HFAP.

The report noted LSC deficiencies may also be cited under the CoP, but provided several examples of problems found solely under the Environment of Care. The citations included:

  • Medical equipment management plans that had not been reviewed annually
  • A lack of documentation that eyewash stations were tested and inspected
  • Multiple patient rooms with emergency pull cords wrapped around the handrail
  • Open ceilings next to patient treatment areas during construction projects
  • A lack of emergency powered lighting in the hospital’s generator room, generator automatic transfer switch room, and surgical suites

Infection prevention

HFAP standard 07.01.02 on Infection Prevention crosswalks with the infection control CoP §482.42(a) and requires the hospital “to develop a system for identifying, investigating, reporting and preventing spread of infections among patients and personnel.”

An example of a surveyor citation was “significant rust on the horizontal top surface” on 13 metal cabinets—each located next to a patient bed in either preop or postop surgical services. Some of them had patient supplies stored atop the rust.

Other problems included:

  • A review of policies and procedures for processing instruments that were several years old
  • Items in the kitchen that did not have a “use by” date
  • A pediatric bronchoscope that was stored uncovered with no apparent date of cleaning
  • A review of scope processing logs that “indicated some scopes had not been reprocessed for up to 12 days”

The standard requires surveyors to determine if the hospital, among other things, “maintains a sanitary environment” and conducts “active surveillance”

The review offered a separate section just on problems found with Life Safety. The problems most often cited during more than 50% of hospital surveys involved testing of fire alarm systems, testing and inspection of water-based fire protection systems, gaps in ceilings with fire safety barriers, and a lack of labels on electrical panels connected to utility systems.

Take advantage of HFAP resources

In his foreword, Ley encouraged organizations to partner with HFAP staff to improve compliance and patient safety.

“Pre- and post-survey and throughout a term of accreditation, HFAP staff members are available to support problem-solving and lend process expertise. We use data—like the findings of this year’s Quality Review—combined with knowledge gained from daily interaction with our accredited organizations to develop tools and educational programming. We also use this information to enhance our customer service by bringing new solutions like HFAP Compass, our new IT platform, that will launch later this year,” he wrote.

Founded in 1945 by the American Osteopathic Association, HFAP in 1965 was the first AO to be approved by Medicare to deem hospitals as eligible to bill CMS for services. HFAP was acquired by AAHHS in 2015, and while officials initially said there would be a name change, ultimately AAHHS went with the legacy branding of HFAP, recognizing its long history as an AO (IJC 4/16/18).

Like other AOs, HFAP has been updating its standards in the last few years to reflect many of CMS’ concerns about patient safety, including ligature risk and suicide prevention. In addition, HFAP was among the AOs asked to provide information about how it conducts patient safety surveys after members of Congress expressed concerns.

In addition, late last year CMS published a request for public comment on whether AOs like HFAP, The Joint Commission, and others have conflicts of interest providing consulting services to the organizations they also survey. HFAP, like others, told CMS that educational resources offered to healthcare organizations are never conducted by anyone involved in the survey process.


Healthcare Safety Leader asked HFAP officials to discuss its most recent quality review and upcoming initiatives, as well as the changes and concerns from CMS. The following is the written response from Angela FitzSimmons, director of marketing and communications, Deanna Scatena, RN, assistant director, Certification/Accreditation SIT, and Karen Beem, MS, RN, with Standards Interpretation.
The questions and answers have been lightly edited for clarity.

Q: Your standards were recently updated, many to reflect CMS concerns about ligature risk and suicide prevention. Does this quality report include citations under the old or new patient harm risk standards? Were there other standards that are in this report that have since been changed, and if so, how?

A: The Quality Review covers all surveys that took place in 2018, and that was a year of significant regulatory change. In that time frame, there were three versions of the acute care hospital manual in effect: the 2017 edition (until March 1, 2018), the 2018 edition (until September 20, 2018), and the 2018v2 edition.
It’s the 2018v2 manual that includes CMS regulatory changes related to environmental risk assessment for ligature risk, as well as new standards for legionella risk, texting of PHI, and swing beds. That means that a minority of the surveys reflected in this report include those standards.

Q: The introduction from Gary Ley talks about surveyors working with organizations to improve—is this part of the accreditation fee? Or are these consultant services, and if so, do you have a firewall between consultants work and the surveyors work?

A: HFAP’s approach to accreditation for almost 75 years has been based on an educational survey experience for the organization. HFAP surveyors recognize that each organization has a distinct culture and a unique capacity for excellence. They bring evaluative expertise as they assess the organization’s compliance with the standards, but they also bring the experience of having seen how many organizations have solved similar problems. They share observations about ways to improve—sometimes even in areas where the organization is already compliant.

Outside of the accreditation program, we do offer educational opportunities including webinars, classroom, and on-site programs. For all our surveyors, there is a firewall designed to prevent conflicts of interest—actual or perceived—between their work as HFAP surveyors and any other relationships they may have with an individual organization. But none of the programs under HFAP Academy are the kind of services a consultant provides.

Q: What is new about HFAP Compass, the new IT platform?

A: HFAP has undergone a change of ownership that has been a very careful, stepwise process. While CMS has a lot of experience with provider and supplier organizations changing ownership, an ownership change in an accreditation organization from AOA/HFAP to AAHHS/HFAP was a first.

The final piece of our CMS-approved transition is the implementation of our new IT system with a customer portal called HFAP Compass. HFAP Compass is a web-based platform where customers can login to review the standards, manage their accreditation and certification applications and supporting documentation, communicate organizational changes, and access additional resources. It’s going to streamline the process for the customer, for our staff, and for our surveyors by integrating data tools and giving us new data analysis capabilities.

Q: The summary notes that the top deficient standards involved physical environment and infection prevention, and Life Safety citations were also high. How does all this compare to previous years, and is this a reflection of concerns CMS has expressed to Congress?

A: Life Safety citations have been among the most frequent because a hospital’s physical environment is in a state of constant change and the compliance requirements for Life Safety are very regimented. Infection prevention is a frequent citation because it’s such a broad category of patient care and safety, encompassing every aspect and location of hospital services from clinical areas to storage.

Q: The report does a good job of providing tips for compliance and improvement—are there any general concerns or tips for compliance officers about what to focus on specifically? What is the overall concern for 2019 and going forward?

A: Frankly, reading the standards is always a good first step that many organizations overlook. HFAP would always encourage approaching the standards from the perspective of promoting patient safety and reducing the potential for harm or serious injury. Infection control practice and comprehensive environmental risk assessments are two areas where this connection should be obvious.

A newer concern is the development, or adoption, of patient screening tools to identify those at risk of harm to self or others. With these in place, hospitals are expected to provide orientation and annual training to all employees on the subject of identifying patients at risk.

Q: The report speaks for itself to a large extent. But there are a lot of hospitals struggling with making ends meet, and anything that costs more resources is a problem—yet patient safety is the main concern. What is the overall message that leadership or C-suite folks should hear from this?

A: The main message is that quality improvement is a cultural value. Leadership needs to understand that quality activities reduce risk and should be used along with financial metrics. Quality is intimately tied to finance because proactive evaluation and course correction is always going to be more cost-effective than remedial action taken after there has been a breach in quality.

If an organization views accreditation as a triennial exercise, there’s almost certainly going to be a lot more resource expenditure than if the pattern of policy, implementation, evaluation, reporting (the basis of the standards) is recognized and consistently reviewed.

Additionally, when we conduct a survey and point out an area of noncompliance, we never expect a cookie-cutter plan of correction. Instead, we’re looking for how this specific organization is going to make a change that will be meaningful and sustainable within its own setting.

Q: Besides the new IT platform, what changes, if any, are forthcoming to help hospitals, or to improve both hospital and AO performance?

A: HFAP tries to practice what we preach by working in an environment of continuous improvement. We’re finding more ways to collaborate with other healthcare nonprofits; we hope to be sharing some of these new relationships in the near future.

We also try to create networking opportunities to connect customers with each other whenever possible. For example, our certified stroke centers can participate in quarterly community of practice calls in which they learn from each other. It fosters an enthusiasm about change when you see others succeeding and sharing lessons learned. That’s what the Quality Review is intended to do.

Find the 2019 HFAP Quality Review online at https://hfap.org/media/Annual_Quality_Report/2019_Quality-Report.pdf.

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