New Year’s Day --with its resolutions, new beginnings, and fresh start attitude-- is a perfect time of year to reflect on continuous improvement and making ourselves better as not only individuals, but as companies set up to serve the public and our customers. It is also a good time to review ways to improve our bottom line, our operational efficiencies, our general attitude, and our business practices. This sometimes requires revisiting mistakes from our past, things we did wrong, and looking at how we’ve improved them. Deficiencies from our past surveys are certainly a worthwhile thing to look at it in an effort to improve.
One issue that companies seeking accreditation sometimes ask about is why HQAA notes on the written report when deficiencies are “repeat”. This designation means that a company has had deficiencies at a given standard in the past and they are repeated in the current cycle. The questions usually center around why that information would be useful, important, or even relevant?
Noting that a deficiency is repeated is done for several very good reasons.
First of all, it is done to gather and maintain statistical information about which standards organizations have issues with in terms of compliance. HQAA tracks the standards that are most frequently cited in surveys as deficiencies. It also tracks which ones are most frequently repeated. Tracking which ones are most often repeated helps HQAA understand where educational opportunities exist and where additional coaching and survey time are needed. Knowing that organizations frequently struggle with complying with a particular standard, and that they struggle repeatedly even after their first survey, is useful in crafting educational support such as our Power Packs, or even the topics covered in this Blog.
Secondly, it helps HQAA determine what post survey follow up is needed to ensure compliance. If an organization is non-compliant once, the follow up can be as simple as documentation in written, narrative form that they have achieved compliance. If they repeat the same issue again or repeatedly, HQAA sometimes elects to do more intensive follow up including written desktop reviews during or throughout the three-year cycle. A good example of this is an organization cited at the QM standards because they haven’t documented required quality improvement activities. The requirement is that quality improvement meetings are held and reports generated quarterly with yearly summary reviews of the program. If an organization fails to comply with this standard repeatedly, the follow up might be to submit reports yearly, so that the accreditation agency can be sure of compliance throughout the three-year accreditation cycle rather than just once every three years. In some cases, the fact that an organization is repeatedly non-compliant might warrant a focused survey specifically because the issue has been repeated.
Last, and perhaps most important, noting that a deficiency is repeated should help an organization determine where their own learning needs are and structure their own continuous quality improvement. Surveyors cite organizations to point out areas of non-compliance with the goal of helping an organization improve by becoming compliant. Noting repeat deficiencies help clarify that a process or procedure or license or piece of paperwork continues to be deficient and still does not meet the intent of the standard (or law or regulation). It is HQAA’s hope that this ensures that an organization realizes they have to make some change and realize the importance of compliance.
When you have repeat deficiencies, treat them as priority areas that need corrected once and for all. Look for the root cause of whatever the issue is, and work collaboratively within your organization to find a “fix” that will be permanent. Concentrate efforts on understanding not only why the issue came up, but also why the organization was unable to maintain the fix over time. Why did the organization slide back into non-compliance? Seek help from HQAA or some other outside support agency/consultant if necessary. Fix the issue for the long term and improve your organization.
“Those who fail to learn from history are condemned to repeat it”—Winston Churchill in a 1948 Speech to the House of Commons
