University Hospital has just received its report card, and Executive Director Rick Fullmer is beaming with pride.
The hospital earned a 91, the best preliminary score it has ever received, beating the national average of 88 and its previous score, which was also 88. The improvement may seem incremental, Fullmer explained, but it is commendable under the current circumstances.
“The joint commission has significantly strengthened its standards over the last couple of years,” Fullmer said. “It’s much more rigorous today. A score in the 90s is highly unusual.”
The Joint Commission on Accreditation of Healthcare Organization (JCAHO) is an independent, not-for-profit organization that evaluates 18,000 hospitals and clinics nationwide. These healthcare organizations seek accreditation from JCAHO partly for public assurance and partly because the certification is required for Medicare reimbursement. University Hospital pays JCAHO $50,000 for the service every three years.
According to Fullmer, the toughened accreditation process was motivated by a recent Institute of Medicine report that estimated more than 90,000 deaths result from medical errors.
Four surveyors?one former hospital administrator, one physician and two senior nurses?inspect the hospital for five days, compared to three surveyors for three days in the past.
“They turn everything over,” Fullmer said.
The surveyors put pennies under the doors to test compliance to the fire code, which requires a specific clearance between the door and the floor. Finding a bar of soap instead of a soap dispenser in the psychiatric unit, the inspectors “scolded” hospital administrators because the practice makes transmission of infections more likely, Fullmer said.
In addition to the score, the commission gives each hospital a preliminary report containing a set of recommendations for improvements. The hospital received four type-1 recommendations, down from six in its previous report in ’88. Type- 1 recommendations must be resolved within a specified period before the hospital receives its accreditation. The hospital is appealing two of them while JCAHO prepares the final report this month.
The report also praises the hospital by listing its “best practices.” JCAHO stores these reports in its library, so other hospitals trying to implement the same procedure can use them as models.
“The commission was very complimentary,” Fullmer said. “There’s a full page write-up on [our] best practices.”
Because the report is still preliminary and cannot be released to the public, its details were relayed through the hospital. The two type-1 recommendations the hospital is appealing are: 1) the credential validation process of existing faculty members, and 2) the low attendance at medical board meetings by physicians who can admit patients. Fullmer said the former has been corrected and the latter has no relevance to the quality of care at the hospital.
The other type-1 recommendations are the inconsistent standard of care among the hospital’s clinics at different locations, specifically the preparation of intravenous therapy; and the inadequate documentation of certain dental residency training procedures.
The hospital’s best practices include:
?Medication planner for transplant patients at the Dumke Kidney Clinic.
?Emergency room pain assessment protocol.
?Policy regarding patients’ usage of nutritional supplements and herbal products.
?Hand-hygiene compliance.
?Improvement in patient safety.
?Drug management policy?not allowing physicians to give out drug samples.
?Research and reporting on usage of the drug Enoxaparin, an anti-blood-clotting agent.