Accreditation options update: Understanding the Healthcare Facilities Accreditation Program (HFAP)

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This article was previously published in Becker’s Hospital Review. Compass Clinical Consulting has updated the content to reflect changes in the Accreditation Options since previous publication.

In this article, our second in the "Accreditation Options" series, which reviews some of the options for hospital accreditation by organizations with deemed status from CMS, we discuss the Healthcare Facilities Accreditation Program (HFAP).

The Healthcare Facilities Accreditation Program (HFAP) is the accreditation process that grew out of the former hospital approval process of the American Osteopathic Association.

Founded in 1945, this accreditation program is the oldest continuous hospital accreditation organization in the United States. HFAP has experienced growth well beyond its traditional base of osteopathic hospitals to encompass over 400 acute care hospitals, critical access hospitals, and laboratories.

HFAP also provides accreditation services for ambulatory surgical centers, ambulatory care/office-based surgery, and behavioral/mental health facilities. HFAP provides certification in the disease management program/centers of excellence for comprehensive, primary and “Stroke Ready Center” certification, lithotripsy certification, and wound care certification.

On October 1, 2015, the Accreditation Association announced that it had acquired the HFAP program from the AOA. Under this arrangement, the management and operations of HFAP were placed under the direction of the Accreditation Association for Hospitals and Health Systems (AAHHS). Until AAHHS receives deeming authority for HFAP services, the AOA will continue as an operational partner. AAHHS, a partner of the Accreditation Association for Ambulatory Health Care (AAAHC), was created in 2012 and focuses on accreditation needs of American hospitals having 200 beds or less with an average daily census of less than 100.

By partnering with AAHHS and AAAHC, HFAP can provide a more comprehensive range of accreditation programs to its clients, thus eliminating the need for holding accreditation with multiple organizations.

HFAP's organizational mission is to "advance high quality patient care and safety through objective application of recognized standards." The standards meet or exceed the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs), with which they are aligned closely in intent and execution.

In fact, 80% of the HFAP standards "cross-walk" to the CoPs for each type of facility it surveys.

In addition to meeting the CoPs, HFAP structures its standards with a focus on patient treatment, quality improvement, patient safety, and environmental safety.

In the hospital accreditation manual, there are 32 chapters with four chapters reserved for future use. Note that HFAP adopted the national Quality Forum’s Safe Practices and utilizes the CMS Hospital Patient Safety Initiates (PSI): Discharge Planning Worksheet, Infection Control Worksheet, and QAPI Worksheet.

Survey process
Once a hospital or healthcare organization has decided to pursue HFAP accreditation, it must first submit an application, followed by a survey. HFAP surveys are performed unannounced every three years (two years for laboratories), as required by CMS deeming rules.

Survey teams are composed of a physician – who serves as team leader – a nurse, a hospital administrator, and a life safety specialist. Surveyors are paid volunteers drawn from current HFAP-accredited organizations, who are oriented to the survey process through extensive and ongoing HFAP-sponsored education. In the hospital setting, surveyors focus on the hospital meeting core functions of assessment, patient participation, treatment, nutrition, medication use, discharge coordination, environmental safety, patient safety, infection control, quality improvement, and information management.

The length of the HFAP survey is determined by the hospital's size and complexity of services provided, the presence of excluded units and/or swing beds, and off-site locations.

HFAP surveyors' assessment of compliance is straightforward: compliant, not compliant, or non-applicable. When deficiencies are identified, surveyors discuss compliance options with hospital staff. Organizations then submit a plan of correction (PoC) in response to identified deficiencies. Upon completion of the survey, the survey team makes a report to the HFAP Central Office, which reviews the report and makes a recommendation to the AOA Bureau of Healthcare Facilities Executive Committee, which then makes the final accreditation decision.

Decision categories for HFAP accreditation are as follows:

• Accreditation (three-year term)
• Accreditation (requiring a follow-up survey within the three-year term)
• Denial of accreditation

Facilities that have one or more Condition of Participation/Condition for Coverage deficiency cited during their survey are subject to a full or focused resurvey.

HFAP implemented the "10 and 10" policy, which means that the final survey report will be available electronically to the organization within 10 business days and that the organization must respond with a PoC for all deficiencies, or appeal the findings, within 10 calendar days. Once a PoC has been accepted by HFAP, an accreditation decision is released. The facility may be required to submit interim progress reports (IPR) in order to demonstrate continued movement toward compliance and/or sustained compliance. Though summary statistics for accreditation results are not publicly shared, there have been no reports of accreditation denial.

The most recent statistics from HFAP regarding the most frequently cited standards for acute care hospitals are from the 2016 surveys and were:

1. 11.00.01 - Condition of Participation: Physical Environment
2. 15.02.00 - Restraint or Seclusion
3. 07.01.01 - Infection Control Officer (ICO)
4. 07.01.02 - Infection Prevention
5. 03.01.01 - Medical Staff Bylaws
6. 01.01.23 - Contractor Quality Monitoring
7. 15.02.10 - Orders for Restraint or Seclusion
8. 25.01.03 - Security of Medications
9. 3.00.01 - Life Safety Code Compliance
10. 10.01.08 - History & Physical Update Requirements
11. 16.00.04 - Staffing and Delivery of Care
12. 30.00.10 - History & Physical
13. 10.01.07 - History & Physical Requirements
14. 10.01.16 - Informed Consent
15. 12.00.01 - Data Collection & Analysis: Program Scope
16. 12.00.03 - Patient Safety, Medical Errors & Adverse Events
17. 15.01.03 - Patient Grievances
18. 15.01.04 - Governing Body Responsibility for the Grievance Process
19. 15.01.05 - Timely Referrals
20. 11.01.02 - Building Safety
21. 03.04.03 - UR Review Requirements
22. 15.01.07 - Grievance Process Response Time Frames
23. 19.00.02 - Safety for Patients and Personnel
24. 30.01.07 - Post-Anesthesia Assessment
25. 30.01.05 - Pre-Anesthesia Evaluation
26. 30.01.00 - Condition of Participation: Medical Leadership for Anesthesia Services

The HFAP accreditation survey fee is based on the size and volume of the organization being surveyed. Participating hospitals pay a one-time triennial registration fee. In addition, they are required to reimburse the direct costs of performing the survey itself. This area is where the variability in pricing comes into play, as costs of conducting the survey depend on the number of surveyors assigned to the hospital or health system.

HFAP provides the hospital with free access to an online manual, which is also accessible as a PDF. Like TJC and unlike DNV GL and CIHQ, HFAP also charges participating hospitals for a hard copy of its Accreditation Standards Manual. Though they do not appear to be aggressively marketed, HFAP does provide additional consultations, free webinars, and blog posts including CMS updates, and has added live education programs.

HFAP advertises its program as "a straightforward approach to accreditation," and to a large extent, their standards and survey process appear to support their claim. By "cross-walking" its standards to CMS CoPs/CfCs, HFAP makes clear how HFAP accreditation supports CMS compliance. In addition, because HFAP surveyors discuss strategies to mitigate deficiencies when they are identified during survey, hospitals may have a greater opportunity to achieve compliance. If a deficiency is identified, surveyors can draw from their experience and offer solutions, usually on the spot. HFAP encourages its facilities to ask surveyors or the HFAP account manager/standards interpretation staff for suggestions on compliance with the plan of correction.

An exclusive feature of HFAP is that hospitals are provided a copy of the manual, which includes the surveyor scoring procedure. At the time of survey, there are no surprises, as the interpretation of standards is consistent amongst surveyors and standards interpretation staff.

Neither HFAP nor DNV GL requires that hospitals be accredited by their respective organizations to be certified for the disease management program/centers of excellence. This is especially advantageous for hospitals that wish to receive state designations.

Ultimately, HFAP accreditation shares much in common with accreditation by other regulatory agencies, and it may present an attractive option to hospitals wishing to pursue accreditation as a means of supporting CMS compliance.

More information about HFAP can be found at

In the next installment in the Accreditation Options series, we focus on accreditation by The Joint Commission.

Victoria Fennel, PhD, RN-BC, CPHQ has more than 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety, and patient-centered care. As Director of Accreditation and Clinical Compliance for Compass Clinical Consulting, Victoria manages accreditation and compliance engagements, directs client education and advisement, and has led Compass’ efforts to help healthcare organizations prepare for scrutiny from accrediting bodies such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission (TJC), and Healthcare Facilities Accreditation Program (HFAP).

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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