A Validation of Our Hard Work

For hospitals, accreditation from the Joint Commission is the “gold seal” of approval. It means an organization’s patient safety and quality of care standards and practices meet a certain threshold and demonstrate a commitment to provide the highest quality of healthcare services.

Their mission statement reads, "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value".

In order to maintain state licensing and be able to collect federal reimbursement, hospitals must maintain their Joint Commission accreditation. Hospitals such as Greater Baltimore Medical Center are surveyed on a triennial basis – once every three years.

Last week, it was our turn, and a team of four surveyors (physician, nurse, life safety / facilities professional and administrator) arrived at our doorstep for the hospital’s “checkup.” Staff from across the organization spent many hours with the surveyors for four days, visiting both areas seen everyday by our customers such as the inpatient units and the operating rooms as well as the “behind the scene areas” such as the laboratory and our physical plant.

I’m happy to report that it’s time to give each other a pat on the back … We did very well on our triennial Joint Commission re-accreditation survey.

Many people have mentioned to me that this survey seemed less stressful than previous surveys. I’m not sure that anybody believes that it was stress-free, but we have tried to make people believe that we should be ready for the Joint Commission surveyors to come in at any time. In reality, all they are doing is checking to see if our systems are reliable such that everyone, every time, will get the right care.

So I’m glad that many people have gotten into the mindset of continual readiness.

Where we have created standardized work and reliable systems, we did very well on the survey. One of the areas where I was very pleased with the survey results was in the maintenance of the physical plant. I’ve been around long enough to remember the days when the physical plant surveyor would find many problems and here they only found a couple of areas to correct. Michael Forthman and all the facilities management and staff should be applauded.

The reviewers specifically noted how clean the facility was and the overall lack of clutter - thanks Chris Broadway and everyone who works in Transportation. However there was one corridor that we considered non-clinical and had several beds stored in, but the surveyors disagreed and we were cited for that. So the message for staff is still a call to get things like extra beds to the transportation hub and not have these items scattered all over the facility.

Another area in which we need to improve is in clinical documentation of timing and dating orders in those areas where we are not yet using the electronic system, such as the PACU. We have to get better at that and keep marching along to make everything electronic. The non-timing of an order is potentially dangerous and we need to eliminate that problem.

On the clinical side, so much of our work has paid off. Everyplace where we have created reliable systems of care, we did very well. The medical staff review was outstanding. The files were well-maintained and the leadership, under the direction of Dr. Harold Tucker and Dr. John Wogan, have really done a marvelous job of creating ways for us to assess whether or not clinicians are maintaining their levels of competency.

Nursing as a group also did an outstanding job. I was quite impressed with our nursing team’s willingness to present cases to the surveyors and to show what excellent clinicians they are. I sat through a number of presentations and was very proud.

Our Emergency Management efforts, led by Dan Tesch and Michelle Tauson, also were praised, with surveyors very complimentary about our preparations to deal with critical incidents.

(L-R) Carolyn Candiello, GBMC's Vice President for Quality and Patient Safety, and Blood Bank Medical Technologist Ann Eldridge (in white lab coat) meet with one of the Joint Commission surveyors.

One of the areas where high reliability was evident was in the blood bank. I went on a “tracer” with the nurse surveyor and Carolyn Candiello, GBMC’s Vice President for Quality and Patient Safety, and saw the rigor and standardized work around making sure that the right patient gets the right blood. It’s a combined designed effort of physicians, nurses and blood bank personnel to do that. It was something the surveyor was very laudatory of and we should all be very proud.

No one expects that a Joint Commission survey will end without any findings of items that need correction (although the last Gilchrist Hospice Care survey had no findings!) but we received fewer than average findings, and where the reviewers found something, it was generally something we are already working on fixing. Where we find a defect in one of our systems it’s an opportunity to fix it before it creates a catastrophe – see “Every Defect A Treasure”

So, we should all look forward to our next Joint Commission survey about three years from now, not with trepidation, but with excitement when we can once again demonstrate how GBMC is an even more highly reliable healthcare organization.

Tragedy On Campus

Sadly the GBMC family experienced a tragic event on campus Thursday afternoon, with the apparent suicide of a patient. On behalf of the entire GBMC HealthCare organization, I want to express my condolences to the individual's family. Several members of our staff were also personally affected by this situation, and we have provided those individuals with crisis intervention and emotional support. Employees seeking additional support may also contact the Employee Assistance Plan (My Life Resources) at -1-800-437-0911 or www.myliferesource.com access code 9SJ87. This incident reminds us all of the fragility of life.