December 6, 2016
Marshall Medical Centers once again got a favorable review from a very intense survey that evaluates healthcare organizations and the care they provide.
“We are so very grateful for the efforts of all our employees to make MMC a healthcare system that can be trusted to provide safe and high quality care to our community,” said a statement from hospital administrators for North and South. “The Joint Commission surveyors verbalized high praise for the individuals that they interacted with – using adjectives e.g. competent, friendly, knowledgeable, confident, sharp, helpful, etc. Expertise within respective areas clearly showed, and altogether as a team, the result was impressive.”
The Joint Commission accredits and certifies nearly 21,000 healthcare organizations and programs in the United States, and is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
Findings by the Joint Commission are called ‘recommendations for improvement.’
Bill Smith, accreditation officer for Marshall Medical Centers, said the average single hospital receives 19 RFIs. Following the Joint Commission survey in November of the two Marshall Medical Center hospitals and its outpatient facilities, MMC received a total of 10 RFIs, eight of which were corrected before the survey team had finished.
“While we take every opportunity for improvement seriously, we were gratified to hear from the surveyors that they did not feel any of the findings indicated that we were not providing the highest level of care,” he said. “Our survey team was very complimentary of our facilities, staff and medical staff. They stressed we should be proud of the care we are providing.”
Hospitals also can receive ‘conditional level’ and ‘immediate threat to life’ findings, which are very serious and can show a problem with the care provided.
“MMC did not have any condition level findings or immediate threat findings,” Smith said.
The purpose of the Joint Commission survey process is to continuously improve healthcare for the public by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The survey process also serves as a licensing or certifying inspection to allow the facilities surveyed to maintain licensure as a hospital and to bill insurance companies and Medicare.
Marshall Medical Centers are surveyed by Joint Commission every three years in a completely unannounced visit to the hospital. The Joint Commission notifies the hospital at 7:30 am on the day the survey will begin at 8 am. This means the hospital must always be prepared to show compliance with standards, he said. In addition, the survey team can look at records going back three years to ensure that the required quality of care is always being provided.
“The survey lasts about four days and covers every aspect of the operation of the Medical Centers,” Smith said. “The surveyors are physicians, nurses, hospital administrators and engineers and are leaders in their fields, usually with years of experience. During this survey we had a total of six surveyors come to MMC.”
During the survey staff members are interviewed and “traced,” with a surveyor following them through the performance of their duties to ensure that policies are being followed appropriately.
“Surveyors also speak to patients and ask them about their stay and the quality of care they receive,” Smith said. “When they are interviewing patients they do so without Medical Center staff present to help ensure the patient is comfortable providing accurate information. Surveyors review patient medical records looking for proper documentation and to see that the patient received the most appropriate care.”
They also review employee files to ensure that staff members receive proper education and that hospitals are educating and testing employees to make sure they are competent to perform their duties, Smith said. Surveyors meet with department heads to ensure they receive the ongoing education needed to stay current with the ever changing practice of medicine. They also meet with the hospital board to discuss how leadership supports the mission of the facilities and to ensure leadership has involvement in improving the quality of care provided.
“During the survey all areas of the hospitals are visited from the ICU all the way to the kitchen and everywhere in between,” he said. “In each area hospital employees are interviewed about their responsibilities and their knowledge of their duties.”
Even the buildings themselves are closely inspected during a Joint Commission visit to ensure the hospital maintains a safe environment. An engineer reviews documentation of all aspects of building maintenance from the fire alarm and sprinkler systems to the way oxygen is provided to patients.
“In addition to reviewing hundreds of pages of documents on testing and maintenance for the past year, he will also spend the majority of two days touring the building and checking to see that it is being properly maintained,” Smith said. “He will climb into the ceilings, crawl under the floors, go anywhere and everywhere to see how the building is being maintained.”
Marshall Medical did especially well regarding the hospital’s preparedness to respond to disasters, security issues and how it plans to provide care during these incidents, according to Smith.
“The surveyor commented that she thought our group had done some of the best work she had seen in these areas,” he said.
While the main focus is on the hospitals themselves, surveyors also looked at out-patient facilities including centers for physical therapy, wound care, sleep, pain and the Marshall Cancer Care Center to ensure the care those patients receive is the same excellent quality given to patients in the hospitals, Smith said.