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Healthcare Facilities Accreditation Program

Measuring compliance and accomplishment

Freeman Health System is accredited by the Healthcare Facilities Accreditation Program (HFAP). HFAP has been providing medical facilities with an objective review of their services since 1945. The program is recognized nationally by the federal government, state governments, insurance carriers and managed care organizations.

In 1965, with the implementation of Medicare, the HFAP was granted "Deeming Authority" to conduct accreditation surveys of acute care hospitals by the Centers for Medicare and Medicaid Services (CMS). HFAP was also granted "Deeming Authority" to survey hospital laboratories under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and has also been given authority to accredit Critical Access Hospitals, Ambulatory Surgical Centers, and Outpatient Surgical Facilities.

HFAP survey teams monitor a healthcare facility's ability to accomplish the eleven core hospital functions:

  • Assessment: The facility assesses each patient's needs on an ongoing basis.
  • Patient Participation: Patients and family/caregivers possess needed information to facilitate their participation in the treatment process. The facility's treatment processes afford patients the opportunity and the means to make informed decisions about their care.
  • Treatment: The integrated delivery of direct treatment services and the services that support direct treatment address the patient's assessed needs and the patient's responses.
  • Nutrition: The facility meets the nutritional needs of the patient.
  • Medication Use: Patients receive the correct medication in the correct dosage at the right time by the correct route.
  • Discharge Coordination: The patient's post-hospital care needs are addressed.
  • Environmental Safety: Patients and staff experience a safe environment that protects them from biomedical hazards, accidents and threats to security.
  • Patient Safety: Patient's individual safety needs are addressed.
  • Infection Control: The hospital's processes protect patients and staff from nosocomial infections and communicable diseases and manages outbreaks when they occur.
  • Quality Improvement: The facility's quality assessment and improvement program is a continuous, integrated activity within the facility.
  • Information Management: The information management system assures the confidentiality, security and integrity of information. The system captures, analyzes and transmits patient specific and organizational data accurately and timely.