4 Tactics to Prepare for an HFAP Accreditation Survey

The nature of ASCs could make efforts to achieve accreditation more challenging. As smaller healthcare delivery systems with more intimate staffing/governing structures, leaders and employees often serve in multiple positions, juggling numerous responsibilities in addition to patient care. Alexa Simkow, director of surgical services at Botsford Hospital in Farmington Hills, Mich., and accreditation surveyor for Healthcare Facilities Accreditation Program, discusses four tactics to help ASCs achieve accreditation.

1. Gain and maintain a comprehensive understanding of accreditation standards. Ms. Simkow says noncompliance to HFAP standards can most frequently be attributed to failure to read the standards or document action steps to meet the standards. These failures increase the chance of citations during inspections.

"The HFAP standards are incredibly clear and concise. They tell you exactly what you need to do to meet the standard, so it becomes obvious whether or not a facility has even read the standards," she says.

Ms. Simkow says the facilities that really meet and exceed this standard are those that go the extra step to create a manual for accreditation, with supporting documentation outlining action steps for each standard. "It's an excellent way for facilities to show surveyors how they are meeting each and every single standard."

2. Ensure staff members are competent with standards. A keen understanding of HFAP standards requires staff members to develop a deep understanding of why the standards are there in the first place. Ms. Simkow says an immediate red flag during her inspections is when staff members cannot explain why certain processes or policies are in place, such as donning of personal protective equipment or terminal cleaning.

"There is so much to understand [regarding infection control] that ASCs must make it a priority to go one step deeper during staff education," Ms. Simkow says. "The facilities that pass the inspection with flying colors have staff that can tell you, without question, why each infection prevention process is in place."

3. Make quality improvement a standard agenda item during meetings. According to HFAP standards, every quality-related effort, such as quality improvement projects, must be well-documented and taken to the governing body. Ms. Simkow says although ASCs generally do a great job maintaining quality, collecting data and implementing action plans, this detail may be easily overlooked.

"A lot of times, surgery center staff simply forget to get approval from the governing body [on matters related to quality improvement]," she says. "I think this happens because a lot of times, the physicians are already part of the governing body. When the surgeons are engaged as clinicians and discussing quality during the day, those issues are not always taken back to the governing body."

Ms. Simkow says ASCs can prevent this by making quality issues a standard agenda item during governing body meetings.

4. Consider the physical layout of the surgery center. Maintaining high-quality infection prevention and control also requires attention to the physical layout of the surgery center. Consideration of the physical plant should be applied to everything, such as sterilization, disinfection, patient privacy or medication storage.

"For instance, there should be sufficient physical space in reprocessing areas to separate clean instruments from dirty instruments or clean linens from soiled linens," Ms. Simkow says. "Another spacing issue ASCs must consider is accessibility, including whether hand hygiene products are close by."

Ultimately, a culture of patient safety will play the biggest role in achieving compliance with accreditation standards. "A physician surveyor and I recently conducted a survey of an ASC. By the end of it, neither of us could find any deficiencies, and it was because the staff didn't just simply follow the standards — they truly believed their process and procedures were the right thing to do."

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