At the 18th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 28, Bernard McDonnell, DO, a retired physician and current surveyor for Healthcare Facilities Accreditation Program, outlined the HFAP accreditation process and discussed key strategies for preparing for the survey.
Understanding the process of an HFAP survey is critical for both quality and financial reasons, Dr. McDonnell said. HFAP's accreditation standards closely reflect standards under Medicare's conditions of participation. The HFAP survey itself is a two-day process and covers 13 areas, including a full review of surgery center governing bodies, surgical services, credentialing, human resources, physical environment and more. Healthcare facilities are up for re-accreditation every three years.
In addition to a comprehensive survey of those 13 areas, HFAP surveyors also follow a patient (pending permission from both the patient and his or her physician) through the entire care process, starting from registration through discharge.
Dr. McDonnell provided these strategies for preparing for an HFAP survey:
1. Purchase a manual from the HFAP central office and review the handbook.
2. Read every standard. Dr. McDonnell said it is critical surgery centers take the time to understand each and every single standard so they know exactly what to expect.
3. Understand scoring and weight for each standard.
4. Be familiar with CMS' standards. Understanding how CMS' and HFAP's standards mirror one other could be beneficial in the long-term.
5. Share standards with the appropriate staff.
6. Conduct a mock survey, appointing a lead staff member with the most knowledge to conduct the mock survey.
7. Conduct a walk-through with a checklist as if you were (1) a surveyor and then a (patient). "[Surgery center medical staff] see the same things every day over and over again," Dr. McDonnell said. "You can't become complacent. Bring in a fresh pair of eyes, maybe from upper management, to help assess these areas."
8. Audit patient records to ensure completeness.
9. Make it a habit to talk about quality improvement and infection control. "Quality must be pervasive," Dr. McDonnell added. "Everybody must be involved. Everything seems nurse-driven, but you have to make sure the physicians are involved, too."
Dr. McDonnell closed out the session by clarifying the last stages of the survey process, which include an exit interview with staff, physicians and any top-level management such as CEOs, and an explanation of their findings from the survey.
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Understanding the process of an HFAP survey is critical for both quality and financial reasons, Dr. McDonnell said. HFAP's accreditation standards closely reflect standards under Medicare's conditions of participation. The HFAP survey itself is a two-day process and covers 13 areas, including a full review of surgery center governing bodies, surgical services, credentialing, human resources, physical environment and more. Healthcare facilities are up for re-accreditation every three years.
In addition to a comprehensive survey of those 13 areas, HFAP surveyors also follow a patient (pending permission from both the patient and his or her physician) through the entire care process, starting from registration through discharge.
Dr. McDonnell provided these strategies for preparing for an HFAP survey:
1. Purchase a manual from the HFAP central office and review the handbook.
2. Read every standard. Dr. McDonnell said it is critical surgery centers take the time to understand each and every single standard so they know exactly what to expect.
3. Understand scoring and weight for each standard.
4. Be familiar with CMS' standards. Understanding how CMS' and HFAP's standards mirror one other could be beneficial in the long-term.
5. Share standards with the appropriate staff.
6. Conduct a mock survey, appointing a lead staff member with the most knowledge to conduct the mock survey.
7. Conduct a walk-through with a checklist as if you were (1) a surveyor and then a (patient). "[Surgery center medical staff] see the same things every day over and over again," Dr. McDonnell said. "You can't become complacent. Bring in a fresh pair of eyes, maybe from upper management, to help assess these areas."
8. Audit patient records to ensure completeness.
9. Make it a habit to talk about quality improvement and infection control. "Quality must be pervasive," Dr. McDonnell added. "Everybody must be involved. Everything seems nurse-driven, but you have to make sure the physicians are involved, too."
Dr. McDonnell closed out the session by clarifying the last stages of the survey process, which include an exit interview with staff, physicians and any top-level management such as CEOs, and an explanation of their findings from the survey.
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