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JCAHO surveys a success for health system
Sept. 20, 2002
The (preliminary) results are in.
The Joint Commission on Accreditation of Healthcare Organizations surveyed St. John's Regional Health Center, Mercy Villa, Breech Regional Medical Center, Carroll Regional Medical Center and St. Francis Hospital in August.
The health center received a preliminary score of 93. Mercy Villa and Transitional Care Unit (reviewed under the same standards as Mercy Villa) received a score of 98 and the home care programs received a 93. Breech Regional Medical Center received an 87 for the hospital and a 96 for the home health and durable medical equipment (DME), equipment that is distributed to home health care patients. Carroll Regional received a 90 for inpatient and a 92 for home health.
JCAHO surveyors make recommendations for improvement and score an organization's performance against accreditation standards. The JCAHO accreditation is a nationwide seal of approval that indicates a health care organization meets high performance standards.
St. John's Director of Quality Resources Diana Henderson said 10 surveyors inspected the health center over a period of four days and the year and that a half of preparation for the survey paid off. She added that in addition to the survey, the surveyors wrote more than a page of gratifying remarks, which she said, "is not a routine task."
"We are a Mercy organization and we don't want to provide average care, we want to provide stellar care," Henderson said. "I believe that that was evident in our JCAHO survey. The surveyors complimented us over and over about how excellent or outstanding an area was. They said many times that they had never seen a unit set up in such a way that made it not only a state-of-the-art facility, but also state-of-the-art in the manner of care that is being provided."
Mercy Villa Administrator Don Swafford said Mercy Villa's preliminary scores were excellent and the staff should be very proud.
"Our staff did an excellent job," Swafford said. "We have state surveyors at Mercy Villa twice a year, so we try to carry on business as usual, but there is added pressure with JCAHO. The most important thing is that the surveyor said we showed kindness, respect and dignity to our residents. If our surveyor left using words like that then we did our job, and that makes me proud of our staff. That should also give our residents and their families a sense of confidence also."
Swafford added that a couple of weeks prior to the JCAHO visit, five state surveyors visited Mercy Villa for a week and found the facility deficiency free.
Breech Regional Medical Center President Gary Pulsipher said the preliminary scores for Breech were much better than they were during the previous survey and the employees at Breech put a lot of effort into the success of their survey.
"We had some problem areas that were identified in the last survey," Pulsipher said. "We have spent a lot of time on those areas and we are very pleased that our scores have increased. Our surveyors were very complimentary of our staff and how friendly they were. People make all of the difference, especially in a small hospital."
Carroll Regional Medical Center President David Dennis said the four-day survey went very smoothly and showed the highest level of professionalism from his staff.
"We are a small facility and we take care of people, that's our business. I just told them to do what they do best," Dennis said. "We are an accredited hospital and it doesn't get any better than that. It is the job of JCAHO surveyors to find areas of improvement, so I think we couldn't ask for anything better."
Henderson said that while the preliminary scores were excellent, the final scores would be received approximately 45 days from the survey date.
Henderson added the survey was more intense this year than it had been in previous years. She said it was a lot more stringent and detail oriented.
"Our co-workers stepped up and were very well prepared" Henderson said. "The surveyors were very complimentary about how our co-workers were able to provide information during the interview process. They said they were impressed with the amount of professionalism that was displayed in our interactions and our physician participation not only in the survey, but also in the good, quality care that they provide here."
Henderson added that St. John's always wants to further excel in care and service, so by making the JCAHO standards part of our everyday routine it enables us to do extremely well during the survey. She added that preparations for the next survey are already in the works.
"Some areas were identified as improvement areas," Henderson said. "So, we are in the process of developing our action plan to address those issues. We always strive to continually improve the quality of care and services we provide. We are in a continual mode of performance improvement."
Swafford said the JCAHO survey went very well as a whole and everyone should be proud of each individual contribution.
"The system as a whole should be very proud, it is a tough survey," Swafford said. "St. John's functions as a system and all of the supportive services helped each aspect of the system to do well."
Pulsipher added the west region hospitals, Aurora Community Hospital and South Barry County Memorial Hospital, will be ready for the next JCAHO survey.
"In a year we will hold a mock survey for these two hospitals, Pulsipher said. "Three years from now they will be ready to be surveyed as well."
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