The Joint Commission on Accreditation of Healthcare Organizations gave an unannounced for-cause inspection at Gov. Juan F. Luis Hospital this week where surveyors identified areas for improvement, though none posed an immediate threat to health or accreditation, according to the hospital.
The survey was triggered by anonymous complaints, according to Wendy Schaeffer, director of media relations at the hospital. The specific nature of the complaints is kept confidential by the Joint Commission, she said.
"It is a way to measure if we are in compliance with standards overall while also preserving the anonymity of the person who made the complaints," she said. The Joint Commission survey team included Dr. Larry Kachik, and Siward Hazelton, RN. The surveyors conducted a general survey and exit interviews with the hospital’s governing board, medical staff and management. They also identified specific changes and improvements to procedure, some of which were immediately implemented; for others, the hospital created a plan of correction, Schaeffer said.
Some of the items flagged were technical violations of procedural protocol, she said. For instance, when the hospital room numbering system changed recently, the labeling of emergency oxygen shut-off valves on one of the units had not been updated with the new room numbering system. The shut-off valve is activated in the event of a fire to stop oxygen flow to a room, to prevent feeding a fire. As a result of the survey, the issue was identified and the box on that unit was relabeled to reflect the new room numbering system, she said.
The surveyors also said written infection control goals for the hospital must always include a statement specifically about increasing hand hygiene, she said.
"Hand hygiene is addressed extensively in (our) policies and procedures regarding infection control," she said. "However, no matter how extensively we have addressed it in the past, the standards require a statement to be written into the actual goals. So, we will update the goals to include that."
Out of over 400 elements of procedure subject to review, the surveyors flagged eight in its preliminary findings, she said. In the near future, the Joint Commission will issue a final report which may or may not include those eight.
The hospital’s leadership and staff have also been working to steadily improve standards wherever possible by a Continuous System Improvement Academy; an interactive forum in which each Joint Commission Standard is reviewed element by element. Self-assessments are made on all criteria and evaluated in an effort to address the hospital’s compliance level. Based on the results of the self-assessment, policies are revised or established for the highest level of compliance with regulatory standards, according to Schaeffer.
In a statement, hospital interim Chief Executive Officer Darice Plaskett described the CSI academy as "a process to provide insight and continuous improvement in daily operations and systems and ensure full accreditation."
Currently, the hospital is fully accredited. Hospitals are accredited every three years while laboratories are accredited every two years.
There are many benefits to accreditation, including simple reassurance that the care one can expect from the hospital meets national standards. Accreditation also affects eligibility for millions of dollars from Medicaid and Medicare.
Established in 1951, JCAHO is an independent, non-profit organization that evaluates and accredits nearly 15,000 health-care organizations and programs in the U.S.
