02/16/06 — Hospital earns top rating after surprise survey

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Hospital earns top rating after surprise survey

By News-Argus Staff
Published in News on February 16, 2006 2:01 PM

Wayne Memorial Hospital has earned the highest three-year accreditation possible, officials announced this week.

The news came on the heels of an unannounced three-day survey conducted by the Joint Commission on Accreditation of Healthcare Organizations, a national group that sets standards for hospitals.

A three-member surveyor team, along with a doctor, nurse and administrator, randomly selected patients and then studied the patients' medical records to evaluate standards compliance at the hospital. Using a new "tracer methodology," surveyors followed a patient's experiences while at the hospital, then spoke with staff members who interacted with the patient. Doctors and nurses providing care were also observed, and patients were also interviewed.

During the site visit, the goal is to determine how well a hospital meets more than 250 different standards. The list contains everything from patient rights and education, to infection control, medication management, and preventing medical errors. Other areas noted are how the hospital verifies that its medical staff are qualified and competent, how it prepares for emergencies, and data collection.

Receiving full accreditation is a major accomplishment, said Shirley Harkey, vice president of patient services.

"The surveyors left here knowing that this is a quality hospital with quality staff," she said.

Ms. Harkey said she was especially pleased with the results because the survey process has been revamped. In the past, commission members did not show up unannounced, nor did they use the tracer methodology. Instead, they spent much time reviewing hospital manuals and policies and studying paperwork.

"We were pleased with the results, and we are going to continue to make some improvements based on their observations and suggestions," Ms. Harkey said. "Meeting and exceeding JCAHO standards is not a temporary thing. It's about always finding ways to exceed standards and patient expectations. Every time a nurse double-checks a patient's identification bracelet or every time our surgical team calls a 'time out' to verify they agree they're about to perform the correct procedure, at the correct site, on the correct patient, they live and breathe the accreditation process."

Founded in 1951, the Joint Commission on Accreditation of Healthcare Organizations is the nation's oldest and largest standards-setting and accrediting body in health care. An independent, not-for-profit organization, the commission evaluates and accredits more than 15,000 health care organizations and programs in the United States, including more than 8,200 hospitals.