Highlights from a week with the Joint Commission and Institute for Medical Quality
At 7:10 am on July 15, 2013, surveyors from the Joint Commission (TJC) and the California Medical Association’s Institute for Medical Quality (IMQ) arrived at Stanford Hospital & Clinics to conduct the hospital's unannounced triennial Consolidated Accreditation and Licensure (CAL) survey. This was the beginning of a weeklong evaluation of the systems and processes associated with patient care, quality and safety. The reviewers evaluated patients' EPIC records, conducted staff and patient interviews, observed and toured the facility and reviewed numerous documents including credential and human resource files, policies and procedures, meeting minutes and management plans.
To ensure a smooth visit, the hospital activated its survey command center, which was staffed by members of the Quality Patient Safety & Effectiveness (QPSE), Patient Care Services and Clinical Informatics departments. A variety of staff escorted surveyors around the hospital, including senior management, clinical lab, respiratory therapy, patient care services, QPSE, engineering and environmental health and safety staff. The survey process was further supported by a cast of hundreds that included every clinical and support department in the hospital, and medical staff, residents and fellows were all involved in the review.
Surveyors had the opportunity to observe many processes, including hand hygiene, TeamCare rounds and invasive procedure time outs, and reviewed history and physical and interval note documentation, as well as how the GME program interacts with the medical staff and the hospital. They randomly selected cases to review and no one was off limits (one surveyor evaluated one of Dr. Norm Rizk's cases).
The survey team identified a small number of items that will require correction. Failure to complete these corrective actions by the designated timeline will jeopardize the hospital’s Joint Commission accreditation status, which is necessary for the hospital to comply with the CMS Medicare Conditions of Participation (CoPs). Compliance with the CoPs is needed for Medicare reimbursement from patient care and GME activities.
On a positive note, the surveyors were exceptionally impressed with many of our physicians. The staff and physicians demonstrated their passion for health care, willingness to work as a team and focus on the patients. The surveyors understood the complexities of the type of cases that are managed by the medical staff, as well as the innovation and technology that are being developed. From the surveyors’ viewpoint, they had run out of things to look at by Thursday night. As such, we were able to give them a Friday morning session with David Gaba and Susan Eller at the Center for Simulation and Immersive Learning.
At 2:15 pm on Friday, July 19, the survey team conducted its formal exit conference with the hospital management team. According to the reviewers' closing comments, Stanford is well along its way on the journey of becoming a high reliability organization, imbedded with a culture of safety. The recommendations for improvements are items that can be easily corrected. The team left impressed with what they saw, and the last surveyor was seen leaving the fountain entrance at 3:00 pm.
Three years of continuous readiness preparation, that included mock surveys, self-assessments, meetings, practice sessions, in-services and trainings, plus a week’s worth of 14-hour days, paid off. We have made a number of improvements since our last hospital survey in 2010, and are living up to our vision of “Healing humanity through science and compassion, one patient at a time.” Thank you for doing what you do; let’s keep it rolling!
If you have questions or comments about the hospital's recent TJC/CAL survey, contact Steve Chinn at email@example.com or (650) 723-6395.
By Steve Chinn, DPM, MS, MBA, Director, Accreditation & Regulatory Affairs