2025 ANNUAL REPORT
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTER
ambulatory surgery centers
acute care programs For ACHC acute care programs, standards are organized in chapters that tie to specific departments or functions. Refer to the legend associated with each chart to identify which chapters are included in the distribution of deficiencies. A dominant percentage indicates that those chapters may offer the greatest opportunity for overall organizational improvement in this particular setting.
0%
100%
29%
18%
9%
19%
25%
Administrative Deficiencies in ambulatory surgery centers were fairly evenly distributed across categories with slightly more deficiencies in standards addressing Administrative and Quality and Risk Management topics. Direct Patient Care Ancillary Patient Care Services Facilities Management
Quality & Risk Management
Direct Patient Care Chapters 9, 10, 11
Ancillary Patient Care Services Chapters 12, 13, 14
Administrative Chapters 1, 2, 3, 8
Facilities Management Chapters 7, 15, 16
Quality & Risk Management Chapters 4, 5, 6
acute care hospitals
critical access hospitals
0%
100%
0%
100%
11%
24%
3%
47%
16%
9% 13%
11%
42%
25%
Administrative In Critical Access Hospitals, the greatest opportunity for improvement is in Facilities Management where deficiencies across the relevant chapters remained at the same level as 2024 findings. Direct Patient Care standards represent the next best opportunity with, not surprisingly, most deficiencies coming from chapter 6 | Provision of Services with its many subsections. Direct Patient Care Ancillary Patient Care Services Facilities Management Quality & Risk Management
Administrative Facilities Management represented the largest opportunity for improvement in hospitals surveyed in 2025, with most of the deficiencies coming from the Life Safety chapter. Direct Patient Care Ancillary Patient Care Services Facilities Management
Quality & Risk Management
Direct Patient Care Chapters 10, 16, 17, 18, 20, 26, 27, 30, 31, 33, 34
Ancillary Patient Care Services Chapters 14, 19, 21, 22, 23, 24, 25, 32
Administrative Chapters 1, 2, 3, 4, 6, 8
Direct Patient Care Chapters 2, 6, 8, 12, 13
Ancillary Patient Care Services Chapters 10, 11, 19
Administrative Chapters 1, 4, 5, 7
Facilities Management Chapters 9, 11, 13
Quality & Risk Management Chapters 7, 12, 15
Facilities Management Chapters 3, 14, 17
Quality & Risk Management Chapters 9, 16, 18
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