Accreditation can often seem scary and a burden to hospitals because it demands strict adherence to specific standards, and noncompliance can have significant implications for reimbursement and operation of the hospital. However, accreditors should be viewed as partners to hospitals because they help ensure hospitals provide top quality care, according to Joe Cappiello, COO of the Healthcare Facilities Accreditation Program. Furthermore, he says working with an accreditor collaboratively can help support and advance a hospital's strategic plan.
Forming a relationship with accreditors
Before coming to HFAP in October 2011, Mr. Cappiello worked at The Joint Commission for 11 years. His experience at two accrediting organizations has taught him the importance of hospitals choosing an accreditor that they can form a relationship with.
"Accreditation is more than simply a business decision — it's a relationship decision," Mr. Cappiello says. "It's the ability to establish confidence within organization[s] that they absolutely believe their accrediting organization knows them, appreciates their uniqueness, is always approachable, and will always be thorough and fair with dealing with them."
Building trust
HFAP aims to establish a relationship based on trust with its accredited hospitals. In its surveying process, it does not have a threshold system in which hospitals get penalized if they get miss a certain number of requirements. Instead, HFAP works with hospitals to identify all deficiencies, create a corrective action plan and follow through on the plan to ensure improvements are made.
"If there was a rigid scoring threshold — where if you had a certain number of standards non-compliant you would get an adverse accreditation decision — that encourages facilities to shield where they might be noncompliant from the survey team," Mr. Cappiello says. "You're encouraging them not to be forthcoming and not to be frank and honest in the way they approach the team." Trying to hide areas of weakness can only hurt hospitals, because quality and patient safety may be compromised if all accreditation requirements aren't met. "At its core, accreditation is a risk reduction strategy," says Mr. Cappiello. "The more thorough the survey, the greater the identification of risk to the organization and the populations they serve, and the greater the opportunity for the organization to mitigate that risk."
HFAP also tries to build trust with hospitals by taking a hands-off approach in its requirements. While hospitals have to meet certain standards, HFAP does not dictate how the hospitals meet them. "We don't want to get in the management business," Mr. Cappiello says. "We don't want to tell them how to run their facilities. We want to provide them with a set of tools and set of guidelines so they can ensure that they are achieving the height of quality, safe care; the methodology by which they do that and ensure that, we leave up to them."
Accreditor-hospital alignment
To get the most value out of a relationship with an accreditor, hospitals should choose an organization that supports their culture and strategic direction. "I believe that no organization, leadership group, business unit, team or individual employee can achieve peak performance without being strategically aligned to the mission and vision of the organization of which they are part," Mr. Cappiello says.
Reducing risk
For hospitals developing a culture of safety and quality, HFAP provides support by reducing the risk of adverse events occurring. This risk reduction strategy is their true value to hospitals, according to Mr. Cappiello. "It's in your best interest to have a third-party, objective assessment of what your risk is, where it is located and how you can mitigate that risk. It's the true benefit of accreditation," he says.
To attain the greatest reduction in risk, and thus the greatest support of a hospital's culture and objectives, HFAP aligns its standards closely with CMS' Conditions of Participation. In fact, 80 percent of HFAP standards are taken directly from the CoPs; the remaining 20 percent are evidence-based standards that have been promoted by organizations such as the National Quality Forum. "It's the quality of the standards, and the direction that the standards provide you for compliance, that is really the factor that determines how effective your risk reduction strategy through accreditation is going to be," Mr. Cappiello says.
In addition, HFAP evaluates each standard when surveying each facility — something that not all accrediting organizations do, according to Mr. Cappiello. "We want to be there and identify for you every potential risk element; that's why we evaluate every standard. There is no sampling methodology, no proxies for compliance; we evaluate every standard, and it is the only way to get a true picture of your compliance status and your potential risk," he says.
To ingrain a culture of quality into a hospital's everyday operations, all of HFAP's surveys are unannounced. Conducting surveys unannounced is designed to motivate hospitals to meet all standards every day instead of ramping up compliance before an announced survey, according to Mr. Cappiello. Following the guidelines are supposed to be part of hospitals' "business day in and day out," he says.
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Forming a relationship with accreditors
Before coming to HFAP in October 2011, Mr. Cappiello worked at The Joint Commission for 11 years. His experience at two accrediting organizations has taught him the importance of hospitals choosing an accreditor that they can form a relationship with.
"Accreditation is more than simply a business decision — it's a relationship decision," Mr. Cappiello says. "It's the ability to establish confidence within organization[s] that they absolutely believe their accrediting organization knows them, appreciates their uniqueness, is always approachable, and will always be thorough and fair with dealing with them."
Building trust
HFAP aims to establish a relationship based on trust with its accredited hospitals. In its surveying process, it does not have a threshold system in which hospitals get penalized if they get miss a certain number of requirements. Instead, HFAP works with hospitals to identify all deficiencies, create a corrective action plan and follow through on the plan to ensure improvements are made.
"If there was a rigid scoring threshold — where if you had a certain number of standards non-compliant you would get an adverse accreditation decision — that encourages facilities to shield where they might be noncompliant from the survey team," Mr. Cappiello says. "You're encouraging them not to be forthcoming and not to be frank and honest in the way they approach the team." Trying to hide areas of weakness can only hurt hospitals, because quality and patient safety may be compromised if all accreditation requirements aren't met. "At its core, accreditation is a risk reduction strategy," says Mr. Cappiello. "The more thorough the survey, the greater the identification of risk to the organization and the populations they serve, and the greater the opportunity for the organization to mitigate that risk."
HFAP also tries to build trust with hospitals by taking a hands-off approach in its requirements. While hospitals have to meet certain standards, HFAP does not dictate how the hospitals meet them. "We don't want to get in the management business," Mr. Cappiello says. "We don't want to tell them how to run their facilities. We want to provide them with a set of tools and set of guidelines so they can ensure that they are achieving the height of quality, safe care; the methodology by which they do that and ensure that, we leave up to them."
Accreditor-hospital alignment
To get the most value out of a relationship with an accreditor, hospitals should choose an organization that supports their culture and strategic direction. "I believe that no organization, leadership group, business unit, team or individual employee can achieve peak performance without being strategically aligned to the mission and vision of the organization of which they are part," Mr. Cappiello says.
Reducing risk
For hospitals developing a culture of safety and quality, HFAP provides support by reducing the risk of adverse events occurring. This risk reduction strategy is their true value to hospitals, according to Mr. Cappiello. "It's in your best interest to have a third-party, objective assessment of what your risk is, where it is located and how you can mitigate that risk. It's the true benefit of accreditation," he says.
To attain the greatest reduction in risk, and thus the greatest support of a hospital's culture and objectives, HFAP aligns its standards closely with CMS' Conditions of Participation. In fact, 80 percent of HFAP standards are taken directly from the CoPs; the remaining 20 percent are evidence-based standards that have been promoted by organizations such as the National Quality Forum. "It's the quality of the standards, and the direction that the standards provide you for compliance, that is really the factor that determines how effective your risk reduction strategy through accreditation is going to be," Mr. Cappiello says.
In addition, HFAP evaluates each standard when surveying each facility — something that not all accrediting organizations do, according to Mr. Cappiello. "We want to be there and identify for you every potential risk element; that's why we evaluate every standard. There is no sampling methodology, no proxies for compliance; we evaluate every standard, and it is the only way to get a true picture of your compliance status and your potential risk," he says.
To ingrain a culture of quality into a hospital's everyday operations, all of HFAP's surveys are unannounced. Conducting surveys unannounced is designed to motivate hospitals to meet all standards every day instead of ramping up compliance before an announced survey, according to Mr. Cappiello. Following the guidelines are supposed to be part of hospitals' "business day in and day out," he says.
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