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Role Of Regulation And Accreditation In Quality

Role Of Regulation And Accreditation In Quality

Role Of Regulation And Accreditation In Quality

The quest and attainment of quality healthcare costs money, work, and dedication.

Accreditation plays a vital role in the collective social norming facet in the quality enhancement of many healthcare organizations. Regulatory agencies are a key part of this, as they are responsible for enforcing specific standards in the United States. The responsibility

of regulatory agencies has expanded swiftly over the last century along with their influence. For an organization to achieve accreditation they must fulfill written standards that cover the atmosphere of care, the conditions of care, and the quality of care. The Healthcare Facilities Accreditation Program, or HFAP, is one such regulatory agency.

Healthcare Facilities Accreditation Program (HFAP)

HFAP is an accreditation organization that is nationally recognized, based out of Chicago, Illinois. HFAP sets accreditation standards that require comprehensive policies, practices, and assessments. They have authority through the Centers for Medicare and Medicaid Services (CMS). Organizations select HFAP to maximize their organization’s capacity to deliver safe, effective, and high-quality care.

History of HFAP

The HFAP has been accrediting healthcare facilities since 1945 and has fallen under Medicare/ Medicaid since its foundation. HFAP was created to conduct an unbiased review of services offered by osteopathic hospitals by the American Osteopathic Association (AOA) and is the oldest continuous hospital accreditation organization in the United States. HFAP was considered a judgment authority to accredit all acute care hospitals under the Medicare Conditions of Participation named in the authorizing Social Security Act. HFAP is also authorized to survey clinical laboratories under the Clinical Laboratory Improvement Amendments (CLIA) (Meldi, Rhoades, & Gippe, 2009, p. 12).

Reason for HFAP’s Existence 

An HFAP assessment offers a thorough roadmap for an organization’s improvement. The organization’s main concentration is the delivery of high-quality, educationally centered assessment experience.

HFAP’s Public Reporting of Quality Indicators


Once a hospital or healthcare organization has decided to pursue HFAP accreditation, it must first apply, followed by an initial survey. The HFAP conducts an on-site, unannounced, evaluation of a facility once every three years as required by CMS.

Where They Are Reported

Assessors relay found discrepancies to the HFAP Headquarters. The inspected facility is then sent a thorough account of found discrepancies. The facility then offers a ‘Plan of Correction’ to HFAP, within a set timeframe.

Why Public Reporting Of These Metrics Is Important

The HFAP best practices emphasize the need to create procedures that identify everyone’s roles and collect up-to-date information to support decision-making (AHC Media, 2018). By “cross-walking” its standards to CMS CoPs/CfCs, HFAP makes clear how HFAP accreditation supports CMS compliance. Also, because HFAP surveyors discuss strategies to mitigate deficiencies when they are identified during the survey, hospitals may have a greater opportunity to achieve compliance (Fennel, 2017).

How HFAP Operates

Current function

While HFAP participates in a variety of federal, state, and local support initiatives to advance patient quality and safety, its primary focus is delivering high-quality, educationally focused survey experience (Meldi, Rhoades, & Gippe, 2009, p. 14).

Organizational structure

HFAP is a nonprofit organization, that is dedicated to its mission to help healthcare organizations attain and maintain the highest standards in patient care. They also aid in compliance with an ever-transforming government’s policies and the perpetually advancing healthcare realm (, 2020).


The AOA Bureau of Healthcare Facilities Accreditation is a committee of healthcare officials and from various roles in healthcare that includes family health, surgery, internal medicine, colleges of osteopathic medicine, and the American Academy of Osteopathy. HFAP is embodied in all key healthcare and quality improvement forums and is a crucial participant in the influencing of healthcare policy.

HFAP’s Impact on Quality

Health Care Organizations

HFAP aids healthcare facilities in delivering the best and most high-quality patient care using reliable standards while continuing the improvement of its survey methods. HFAP provides healthcare facilities with a dependable structure of measurement for improving their practices, which enables them to offer their communities high-quality patient-centered care.

Nursing Practice

HFAP surveyors look to see if hospitals are using continuous education for their nursing staff to educate their nurses on evolving situations like epidemiological, obstetric, and/or a psych crisis. A recent concern is a development, or adoption, of patient screening tools to identify those at risk of harm to self or others. With these screening tools in place, hospitals are expected to provide orientation and annual training to all employees on the subject of identifying patients at risk (Plunkett, 2019, p. 4).

Patient Care

HFAP has a rejuvenated focus on patient safety initiatives mandated by CMS these are discharge planning, utilization review, and infection control processes. HFAP integrates safety standards from a variety of sources to reflect a broad national spectrum. Using the Medicare CoPs as a base and adapting such things as the NQF 30 safe practices and endorsing the Institute for Healthcare Improvement’s “5 Million Lives Campaign” HFAP accreditation standards include current patient safety initiatives throughout (Meldi, Rhoades, & Gippe, 2009, p. 14).


The role of regulatory agencies and accrediting bodies is to safeguard the community against the hazards associated with health and provide numerous programs that focus on quality care for the health and well-being of the public. Quality is an evolving concept. It is not a finite goal but rather an ongoing process that is subject to the changing needs of society and the knowledge, expertise, and creativity of the healthcare team and the scientific community (Siarkowski-Amer, 2013, p. 236). The regulatory agencies of the healthcare industry are tasked to control and safeguard the public health at all levels, with healthcare regulations executed by non-governmental organizations, local, state, and the federal government. The HFAP is one such agency that provides standards and interpretations for its consumers.


AHC Media. (2018). HFAP Offers Tips on Top Survey Deficiencies. Hospital Peer Review, 43(372). Retrieved from


Fennel, V. (2017). Accreditation options update: Understanding the Healthcare Facilities Accreditation Program (HFAP). Becker’s Hospital Review. (2020). Healthcare Facilities Accreditation Program (HFAP). Retrieved July 17, 2020, from

Meldi, D., Rhoades, F. & Gippe, A. (2009). The big three: A side by side matrix comparing hospital accrediting agencies. Retrieved from


Plunkett, A. J. (2019). HFAP 2019 quality review highlights common problems with ligature risk, IC, fire safety. Inside Accreditation & Quality, 1(3), 1-4. Retrieved from

Siarkowski-Amer, K. (2013). Quality and safety for transformational nursing: Core competencies (1st ed.). Upper Saddle River, NJ: Prentice Hall


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Post a total of 3 substantive responses over 2 separate days for full participation. This includes your initial post and 2 replies to classmates or your faculty member.

Role Of Regulation And Accreditation In Quality

Role Of Regulation And Accreditation In Quality

Due Thursday

Respond to the following in a minimum of 175 words:

How do regulations and accreditation help enforce quality healthcare? Discuss ways in which they help to improve the healthcare system.

Due Monday

Post 2 replies to classmates or your faculty member. Be constructive and professional.

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