Our survey by the Joint Commission

Yesterday the Joint Commission re-accredited Community General Hospital for a full three-year term.

The preliminary award of accreditation was announced at the summation conference for senior management, following a three-day unannounced site visit that involved four surveyors. The re-accreditation is subject to review and finalization by the Joint Commission over the next week.

The review was detailed, and the surveyors identified a number of areas for CGH to make improvements – some of these are requirements for improvement (RFIs) for which we have 45 days to make changes that are acceptable to the Joint Commission. Other changes, called supplemental recommendations, are intended to improve CGH performance even further.

CGH received nine RFIs. Improvements are required in the provision of care, namely better documentation involving pain management and conscious sedation. We need to do better in two national patient safety goals: better medication labeling in the operating room and better measurement of the time frames involving critical test value reporting. Other RFIs involve a change in the Medical Staff’s policy on awarding temporary privileges to physicians in emergency situations and improvement in the signing of verbal orders by physicians. The remaining requirements involve the routine testing of the emergency generator and repairs and safety improvements in the physical plant.

We take the Joint Commission’s RFIs seriously, as we do the supplemental recommendations. We have already begun to make the changes needed.

The surveyors followed a “tracer” methodology. They identified patients at random, reviewed their charts, and traced the progress of their care. They interviewed the patients, spoke with their caregivers, and examined documentation and policies specific to the individual patient and the caregivers. The surveyors visited many areas of the hospital, including off-site departments. Noteworthy were comments they made about CGH employees: “bright,” “very knowledgeable,” “willing to listen,” and “not afraid to explain.” They also challenged us to be more consistent in our processes with comments such as “mandatory,” “not acceptable,” and “inconsistent” to describe areas where we need to improve.

I sincerely appreciate the attention and respect afforded the surveyors by the CGH family, but most of all I thank employees and managers for the preparation, competence, and professionalism they bring to patient care every day.

The surveyors noted with interest our preparations for computerized physician order entry (CPOE), which will be rolled out at CGH next year. They said the introduction of CPOE, electronic medical records and other information technology in the coming years should help improve our processes, further lower the risk of error, and avoid some of the documentation issues that were encountered.

I thank members of the Board of Directors and Medical Staff who participated in the Joint Commission leadership conference: Steve Infanti and Chet Amond, current and past Board chairs; as well as Drs. David Halleran, Thomas Hartzheim, Andrew Merritt, and Howard Weinstein, representing Medical Staff leadership. I appreciate the assistance of Mary Kinneman, interim Chief Nursing Officer, who helped the Nursing Division and the management team improve standards compliance and survey readiness. Dr. Fred Goldberg, new in his role as Chief Medical Officer, was helpful in this survey. Thanks also to Brendan McGrath, interim Vice President – Operations.

I especially acknowledge the staff of the Quality Department, which helps the entire hospital monitor and maintain compliance with our policies and with the Joint Commission standards, particularly Sally Ramsden, Director of Quality and Education, and Wendy Tarby, Director of Performance Improvement.

Last month CGH was honored as one of the Thomson Top 100 Performance Improvement Leaders among the nation’s hospitals. This demonstrated our progress in recent years in reducing mortality, improving patient safety, improving length of stay performance, as well as other measures. Maintaining Joint Commission accreditation is further evidence that Community General Hospital provides quality and safe care for our patients – and that we are committed to making ongoing improvements.

Thank you all, and congratulations.