Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 12: QUALITY ASSESSMENT & PERFORMANCE IMPROVEMENT 12.00.01 Data collection and analysis: Program scope Frequency of the citation: 32% Overview of the requirement: The hospital’s QAPI Program includes measurable quality indicators for every department and service including contracted services that are used to monitor the effectiveness and safety of care provided. Comment on deficiencies: Compliance is evaluated through review of the annual QAPI plan with a focus on frequency and detail of data collection.
CHAPTER 15: PATIENT RIGHTS AND SAFETY 15.01.02 Notice and promotion of patient rights Frequency of the citation: 26%
Overview of the requirement: A document of patient rights is developed to include 24 required elements and posted or otherwise available to patients. Comment on deficiencies: Surveyors review the patient rights document to confirm compliance. Findings focused on documents that lacked specific required elements. Examples of ACHC Surveyor findings: ■ Posted statements of patient rights were not congruent with the hospital’s Patient Rights and Responsibilities policy. ■ The patient rights poster does not include the required language that the hospital will not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability. ■ Patient rights documents are missing the following elements: ٝ The right to know the reasons for any proposed change in the professional staff responsible for his/her care. ٝ The right to know the reasons for his/her transfer either within or outside the hospital. ٝ The right to be informed of the source of the hospital's reimbursement for his/her services, and of any limitations which may be placed upon his/her care. ٝ The patient's family has the right of informed consent for donation of organs and tissues.
Examples of ACHC Surveyor findings: ■ The hospital lacked metrics for contracted patient care services. ■ Frequency of data reporting was not identified in the annual QAPI plan.
■ The facility policy, “Sentinel Events,” states that the risk manager will provide quarterly aggregate reports on the number, type, and outcome of sentinel events to the Process Improvement Committee. PI Committee minutes do not reflect that this information is communicated. ■ External data are not used to benchmark program effectiveness and identify opportunities for improvement related to quality indicators selected for each department. ■ Patient care and patient-care associated contracted services lacked qualitative metrics/ benchmarks identified in their contracts, and the required approval of the governing body.
Compliance tips for:
QAPI is an organization-wide program that tracks quality across all departments and locations of the hospital. This standard focuses on the establishment of these metrics: what they are, how and when they are to be collected and analyzed against external benchmarks and prior organizational performance. ■ Inventory all patient care services, including contracted services to ensure that metrics are established for each. ■ Educate contract owners on data collection requirements and reporting frequency. ■ Place contracted services quality monitoring on a reporting schedule for QAPI Committee review and discussion. ■ Research external benchmarks to create goal targets for performance.
Nerd Newbies (understand the requirement)
Compliance tips for:
This standard focuses on the presence, completeness, and accessibility of a patient rights document. Compliance should be simple: every required right is spelled out in the ACHC standard. The language can be copied directly.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Audit for the presence of a patient rights posters in all departments.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
■ Add patient rights education to annual staff training.
Nerd Trailblazers (prepare the path for others)
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