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Heart of the Rockies Regional Medical Center (HRRMC) is anticipating some good news soon from The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO). Earning accreditation or certification from The Joint Commission signifies a commitment to patient safety and quality care.

A team performed a comprehensive survey recently after HRRMC applied for accreditation in January.

April Asbury, Vice President of Patient Care Services at HRRMC said “The biggest advantage is to our patients and the reason we wanted to be accredited – number one, the (hospital) board really felt it was important to have regular surveys that validate our compliance.”

“We have a pretty good reputation for high-quality care, and we seek to always meet all of the quality initiatives as set by the Center for Medicare and Medicaid Services (CMS),” said Asbury.

The state health department does inspections, usually every five years, and Asbury said their assessments also have been very favorable. But the hospital wanted to do more, and seeking a Gold Seal Accreditation from the Joint Commission is the ‘gold standard’ of review for health providers, from hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services.

Accreditation is awarded after successful completion of an on-site survey, conducted by a specially trained Joint Commission team of surveyors who assess compliance with standards of patient care.

Asbury said while the accreditation inspection visit is usually done on short notice by the commission team, the staff did an extensive internal review to help prepare for the inspection visit which occurred June 29 through July 1.

The commission stated its review encompasses tracing patients’ experiences, which involves observing services provided by various caregivers and programs within the organization, as well as hand-offs between care providers. The assessment included on-site observations and interviews; an assessment of the physical facility, and reviews of documents provided by the organization.

While the Joint Commission review is similar to the state health department inspections, Asbury said it requires more. “They have some extra quality initiatives, some extra data reporting and some extra patient safety [criteria] that we have to meet, above and beyond the conditions of participation, so it’s a little bit more comprehensive and thorough.”

The review starts with a ‘tracer,’ a patient who has come through the Emergency Room or following surgery from the Operating Room (OR).…”So they look at the highest risk patients, and then they trace them from start to finish,” Asbury added. “They look at the care, they look at the credentials and training of the caregivers … so any process or person that touched that patient, they dig in deep into audits, into the staff, the personnel, the credentials; they basically do all of their surveying by using tracer methodology.”

The review includes all departments; imaging, the inpatient units, intensive care, emergency department, operating room processes, and more. “Infection prevention is the center of everything they’re observing …” according to Asbury.

The inspectors also give a ‘safer matrix’ report to staff even before leaving the hospital, detailing potential issues regarding patient safety and the scope of those issues, from low level to widespread.

“Almost all the findings were in the low and limited category, meaning low patient harm and very limited findings so we were able to fix them even before they left the building,” added Asbury.

Asbury detailed some other recommendations made:

“There were findings with both the clinical care and environment of care elements of performance. Some examples of the clinical findings were related to documentation of a lot number of saline when preparing tissues, temperature for a saline warmer, specific reason for administering a PRN (“as needed”) medication, a care plan problem, and the link of a current protocol to use of the protocol for patient care,” she stated. “Some examples of the environment of care findings were related to documentation of the specific actions taken in response to instances of the OR humidity dropping below the identified range, suite boundary not clear on the facilities plans, and the bulk oxygen outside of the building requiring a cover.

The issue regarding OR (operating room) humidity and documentation of actions taken, though remedied immediately, requires a second visit within 45 days of the initial visit,” she added. Asbury said the commission’s initial report was excellent. “They said that our compliance was awesome,” noting they cited no swing bed deficiencies, made a few recommendations regarding consistency, and found the staff to be “excellent, available, kind and collaborative,” and surveyors shared “that we as a hospital are on the right track,” she added.

Feature photo: Heart of the Rockies Regional Medical Center. Dan Smith photo.