Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
ACUTE CARE HOSPITAL
This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for ACHC-accredited acute care and critical access hospitals. Data presented in this year’s report span initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
General Results This year, it's all in the details. Frequently cited standards are generally consistent from year to year. Deficiencies are most common when the standard has a large number of required elements. Risk mitigation measures for infection prevention ( 07.02.01 for acute care and 18.02.01 for CAHs) represents a standard that requires compliance across all areas of the hospital. While it remains a frequently-cited standard, we are seeing improvement worth noting. While the frequency of this finding remains high, the severity has decreased by 67 percent due to fewer condition-level deficiencies. Given the breadth of this infection prevention standard and its many required elements, ACHC surveyors most often identify environmental issues that create infection risks, but this trend represents improvements in infection- based systemic failures. We would attribute a portion of this improvement to the ongoing education provided to our organizations. Our team uses deficiency data to identify areas where additional support is needed and develops education accordingly, benefiting all organizations as they prepare for survey. Acute Care Hospital Findings When looking for trends, ACHC Surveyors most often identify missed details. To improve, hospitals must focus on education. Every action requires attention to detail, whether managing security of medications (see 25.01.03 ), meeting established timelines ( 15.02.14 Violent Restraints and/or seclusion: One-hour face-to- face assessment ), recording patient care activities (see 16.00.10 Plan of care ), completing the credentialing and privileging process (see 03.01.15 Application and reapplication requirements ), measuring department
performance (see 1 2.00.01 Data Collection and analysis: Program scope ), or writing policies and procedures for disinfecting instruments (see 07.04.03 Processing flexible and semi-rigid endoscopes ). The required documentation begins with planning and continues through training and evaluation/ assessment. Health care is a team-based activity. This is why we look so carefully at your documentation. For each process, the participants need to pick up their individual responsibility for care delivery in a way that reflects the organization's intention as defined by policy and procedure. This is both a risk management strategy and a quality of care principle that benefits your patients. Critical Access Hospital Clinical and Administrative Results For CAHs, we are taking a close look at nine clinical and administrative standards distributed across six chapters. Standard 06.03.08 Policy requirements: Food preparation and storage (24.01.03 for acute care hospitals) is another consistent challenge. Here, we often see a gap between policy and implementation. Document review demonstrates that CAHs have the right approach, but direct observation often reveals opportunities to do better in practice. This standard also provides an example of required monitoring (for temperature) with flexibility in responding to out- of-range results. Whenever ACHC Standards require monitoring, there is an accompanying expectation that action will be taken when results are outside of defined parameters. Don't neglect to include that action when creating policies and procedures.
Physical environment and life safety results You’ll find the most frequent deficiencies in these areas on pages 30-51 for both acute care and critical access hospitals. These requirements are a focus for facilities teams, so we consider them separately from the clinical and administrative standards. However, maintaining a sanitary and secure environment is not the exclusive responsibility of facilities staff. Renew your engagement with quality ACHC is keenly aware that hospitals of all sizes continue to experience burdens and pressure. ACHC Accreditation is not intended to be a source of stress. We recognize your ongoing investments in improving patient care and we are here to act as a partner, not an adversary. I encourage you, once again, to take advantage of the full range of ACHC resources. This year has seen a new crop of templates and tools
available through ACHCU, including a Universal Risk Assessment that was a frequently requested resource.
We've had a lot of positive feedback about the expanding community of ACHC Accreditation Nerds. I hope to see more of you than ever at our next opportunity to gather for ACHCU Academy. Amelia Island, Florida next March will offer warm weather, inspiring sessions, and access to expertise from our team and your fellow registrants. Bring your team and recharge while earning CEUs and renewing your commitment to the safe, high-quality patient care we all want to deliver!
Deanna Scatena, RN Program Director
achc.org | (855) 937-2242 | 5
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