Hospital survey a success, Critical Access Hospital status effective

8/31/06

MCDH successfully passed its survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on Thursday, August 31.  The JCAHO survey was the final step in the application process for the hospital to become a Critical Access Hospital.

During the three-day survey, JCAHO representatives inspected the quality and safety of the care provided by every department within the hospital and Home Health program.  Nurses and physicians were observed during interactions with patients, and patient charts and medical records were evaluated for their thoroughness and compliance with standards.  The hospital facility itself was inspected for safety and condition.

“From the beginning of my stay here (in May), I have said this is an excellent facility with excellent staff.  Passing the JCAHO survey confirms that.  I am proud of our staff, and the quality service they provide to the community,” said Jon Baker, Interim CEO.

“My preliminary findings indicate that you passed the survey, and your accreditation is effective for another three years,” reported JCAHO surveyor Tom Davis, RN, at his exit interview with staff Thursday afternoon.  His findings become official after review at JCAHO’s Chicago headquarters.

Conducting a survey every three years is JCAHO’s way of ensuring that hospitals stay up-to-date with the standards of care.  Of the hundreds of JCAHO standards, four areas received “Requirements for Improvement,” when the maximum allowable number for CAH accreditation is five.  The areas for improvement reflect some new standards that include implementing procedures to provide patients with a written list of medications to continue upon discharge from the hospital, and to document updated histories and physicals upon admission.  Also required are recording the time of a chart entry in addition to the date and clinician’s signature, and developing criteria and a policy to monitor a new physician’s skills required to administer conscious sedation.  The hospital has 45 days to document 100% implementation of the needed improvements. 

“These surveys always find a few things to improve.  We are glad to implement the actions they recommend, and the surveyor shared many ideas from renowned major medical centers across the U.S. to further improve our care,” said Catherine Rhyne, Chief Clinical Officer.

The health care standards evaluated by JCAHO are ever-changing, as new ways for improving the quality and safety of care are found.  “Keeping up with the standards is an ongoing process, and we are very pleased to pass the survey, as it demonstrates that we are committed to providing excellent quality, up-to-date care here on the coast,” said Susan Bivins, RN, Director of Outcomes Management, who coordinated the survey for the hospital.

MCDH is now a Critical Access Hospital, though it will take about six weeks to receive the higher payments from Medicare due to the records conversion that must take place within the Medicare system.  The effective date for the higher payments is August 31.

JCAHO is the nation’s predominant standards-setting and accrediting body in health care, and focuses on the quality and safety of the care provided by health care organizations.  It is a not-for-profit organization that evaluates and accredits nearly 15,000 health care organizations throughout the U.S.  More information about JCAHO is available at www.jointcommission.org.

###

For more information, call Heather Paulsen at 961-4615.