New Quality Review analyses published in The Surveyor by the Accreditation Commission for Health Care (ACHC) are now available. The special reports include key insights and deficiencies from 2022 survey data, covering a wide range of healthcare environments from ambulatory surgery centers to home care agencies and sleep labs, among others. These resources help organizations benchmark performance against their peers to proactively address common issues as part of continuous quality improvement.
“Leading with education is at the forefront of our development strategy to help support these organizations in their improvement efforts through accreditation,” said José Domingos, president and CEO of ACHC. “We wish to empower our healthcare organizations to address deficiencies head-on with a 360-degree approach to accreditation.”
The data in each edition is presented by organization type and includes examples of surveyor findings along with useful, actionable tips for compliance with program standards. Accreditation program leaders summarize the past year’s survey findings, acknowledging identified deficiencies in their respective areas and offering their own insights into the data and how it can be best used to improve standards of care.
“For most of our programs, this is only the second year we have provided this data, but we aim to continue with these reviews for all our programs to help build upon the partnerships we’ve made and encourage success for those already accredited or seeking accreditation,” added Domingos. “We make sure our organizations maintain quality standards and are given the tools they need to succeed.”
Surveyors recorded deficiencies in the provisions of care and record management across several programs. These documentation inconsistencies affected diverse programs from pharmacy and PCAB compounding, to home health, hospice, home infusion therapy and home care.
Some other key findings from the program surveys include:
- DMEPOS Deficiencies – One newly-identified standard ties to an expectation of familiarity with federal requirements, and the other ACHC standards are identified in the report as frequently-cited deficiencies which tie directly to the federal requirements.
- Sleep Center Deficiencies – An increase in standards identified as out of compliance in comparison to 2021 data may be attributed to the increase of survey volume as sleep labs reopened or pivoted to home-based testing as COVID-19 shifts to an endemic state.
- Acute Care Hospitals and Critical Access Hospitals – Outside of physical environment and life safety standards, quality assessment and performance improvement are repeated deficiencies which ACHC plans to address by releasing new tools and educational resources related to hospital quality programs.
- Ambulatory Surgery Centers – Twelve standards were cited as deficiencies on more than 15% of surveys, an increase over the nine that rose to that level in the 2021 report. Only four of the nine are recurring. These four standards focus on governing body and administration, medical staff and emergency management.
- Clinical Laboratory Deficiencies – Analytic systems were the source of the greatest number of deficiencies, while another three came from provider performed microscopy and waived testing, and laboratory personnel and proficiency testing.