Joint Commission Update: Letter to Employees
To our Riverside Team Members:
As many of you know, The Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission) conducted a two-day, unannounced "For-Cause" survey at Riverside Regional Medical Center during the last week of April. With this letter we will share information related to that visit with those of you who questioned why they were here, what they did during the visit, and the outcomes of the survey.
The Joint Commission performs this type of survey when an individual notifies them of a concern about standards compliance, patient care or safety issues. This notice can come from sources such as patients, employees, media, or other regulatory agencies. Though we are not privy to the actual complaint or allegations, we are convinced the survey was related to the recent changes in our anesthesia management company and the resulting introduction of new anesthesia providers. The Joint Commission surveyor, a practicing anesthesiologist, looked for evidence of compliance with the published Joint Commission standards since all reportable observations and findings must be standards related.
The survey focused on performance in the Medical Staff, Provision of Care, Treatment & Services and Leadership chapters of The Joint Commission Standards. Considerable time was spent evaluating the credentialing process, and numerous files from many of the new anesthesiology providers were reviewed. There were no findings related to the completeness or integrity of the providers files. The surveyor seemed quite impressed with the credentialing process currently in place for both our permanent as well as our locum tenens (short-term) providers. As we have believed all along, the surveyor confirmed that we adhered to our medical staff bylaws, and that our standards for provider credentials were maintained throughout the anesthesia transition process.
The surveyor conducted in-house patient tracers (i.e. followed the same steps that patients would experience as a result of going through a given procedure), and also reviewed the medical records of many patients who had surgical procedures performed during the past few weeks. During the record review, a few findings were discovered (for example, a failure to document a "time out" prior to a procedure, and an un-documented history & physical). As has been our experience in the recent past, we again find that our documentation still needs attention. Failure to document appropriately is not acceptable and, therefore, these findings are not in keeping with The Joint Commission Standards. However, they were not deemed to impact care of the patient or the outcome of their visit in either situation.
The surveyor conducted a special Leadership session which included members of the Administrative Team, Board Members, and Medical Executive Council members. During this session, we discussed the major challenges of replacing a large group of clinical service providers, and the ways leadership and performance improvement can impact the transition. The observations stated there was impressive, and comprehensive, documentation of the planning involved in such a significant undertaking. However, JCAHO did note that a meeting already scheduled for later that same week - a session in which we would adjust our anesthesia quality monitoring priorities to take into account the fact that new providers were being introduced on a continual basis - should have occurred earlier in the transition process.
To summarize: as a result of the "For Cause" visit there was no change in our accreditation status with The Joint Commission. The few recommendations that were made have already been incorporated into a timeline of respective corrective action plans. As with any regulatory agency survey, we learned of new opportunities to improve how we accomplish our routine duties, as well as how best to approach and implement difficult decisions. We must continue to make our documentation an integral part of every action we take: we must support our exceptional care with exceptional documentation.
We welcomed the surveyor and viewed his on-site observations as an avenue to validate the excellent patient care we give at Riverside every single day. Thank you for demonstrating to The Joint Commission, and to the community, how well we work together as a team. Our focus has always been, and will continue to be, providing safe, quality patient care and services to everyone.
Patrick Parcells, M.D.
Senior Vice President, Administrator
Riverside Regional Medical Center
Vice President of Operations
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