National organization gives ETMC Athens high performance marks
‘This is a wonderful place for healthcare,’ surveyor says
By Toni Garrard Clay
Debbie Gardiner didn’t get home until late the evening of Jan. 17. Medical staff meetings that night kept the director of performance improvement and many of her coworkers at the hospital until nearly 9.
Consequently, she expected the next day at ETMC Athens to get off to a slow start.
“I got a call that morning saying, ‘The Joint Commission is in the lobby,’” recalled Gardiner.
Goodbye slow morning.
A visit from the Joint Commission on Accreditation of Healthcare Organizations is a bit like a drop-in from God … if God personally set the standards by which healthcare quality is measured in the
To maintain and earn accreditation, healthcare organizations at least once every three years must undergo an extensive on-site review by a team of Joint Commission surveyors (in this case a physician and a nurse). New to 2006, on-site reviews are unannounced.
“We were one of the first hospitals to undergo the new reviewing process,” said Administrator Pat Wallace. “In the past hospitals received four- to six-weeks’ notice. Now they show up unannounced. It means you have to stay on your toes all the time – which is not a bad thing.”
Part of staying on your toes means being ready at any time for a visit.
“Of course, we had a plan in place for when the Joint Commission arrived, even though we didn’t know when that would be,” said Gardiner.
That first morning, she and other key hospital personnel gathered quickly for the opening conference with the surveyors.
“I called (Human Resources Director) Jennifer Rummell, and she and others took down blocks of names as to who needed to be notified, where they needed to be and when,” said Gardiner.
The two surveyors remained on campus for three days. The majority of their process was executed through patient tracing, meaning they identified patients who were receiving care at that time and proceeded to follow their journeys through the hospital until every department had been reviewed that way.
“They traced most of the time they were here,” said Gardiner, “though there were also scheduled meetings and interviews as well.”
Along with the two surveyors – who split up as they went through the review process – the hospital sent an escort and people to take notes. “So we could learn,” said Gardiner.
The most important thing they learned was at the end of the third day.
Recalled Gardiner: “During the closing conference, one of the surveyors said, ‘This is a wonderful place for healthcare.’”
To say those were welcomed words is an understatement.
“We did very well,” said Wallace.
There are approximately 350 Joint Commission standards applicable to hospitals, with approximately 1,300 elements of performance that make up the standards. After a three-day inspection, surveyors identified only six areas for improvement.