Gila River Health Care: JCAHO Review.

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JCAHO REVIEW: A Stellar Success

For three days in November, 2008, Gila River Health Care GRHC) underwent an in-depth survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to ensure that GRHC standards met required national standards for the accreditation of healthcare facilities. Founded in 1951, the Joint Commission is dedicated to continuously improve the safety and quality of the nation’s health care through a voluntary — and very stringent — accreditation review process. Standards created, maintained, and mandated by the Joint Commission require such rigorous preparation as well as meticulous adherence that the Joint Commission often leaves facilities surveyed for accreditation less than satisfied. JCAHO, however, left GHRC marveling.

Regarding the provision of quality care to the community, Darlene Christiansen, Executive Director of the Joint Commission Accreditation Program, said: “Above all, the national standards are intended to stimulate continuous, systematic, and organization-wide improvement in an organization’s performance and the outcomes of care.” She also stated, “The Gila River Indian Community should be proud that Gila River Health Care is focusing on the most challenging goal – to continuously raise quality and safety to higher levels.”

The Joint Commission Surveyors — Nelson Sirlin, M.D., and Mark A. Trudzinski, Certified Healthcare Facilities Manager (CHFM) — complimented GRHC staff not only on our passion for patient care but also for on our commitment to provide quality care on an ongoing basis. Dr. Sirlin stated, “Take the time to celebrate and be proud. This organization has accomplished a great survey.... It is easy to see the high quality of care that takes place here.”

This survey was the third and final in a series of regulatory surveys conducted in the second half of this year. The first survey occurred in June, 2008, resulting in JCAHO’s full accreditation of the GRHC Laboratory.

In September, 2008, the Centers for Medicaid and Medicare (CMS) conducted the second survey—a full survey of GRHC. During the survey, CMS became aware of an item of notice to which GRHC then presented a plan of action for remedy. CMS accepted this plan.

Gail Shannon, GRHC Director of Organizational Performance, lead the way to ensure that all GRHC staff was well-prepared for the final survey in November, 2008. By e-mailing staff each day till JCAHO arrived, Gail provided recommendations for GRHC staff to give them the help to best prepare for the survey – all of which were simply reminders of what staff should already know and be doing on a daily basis. During the two days that the Joint Commission conducted their survey at the hospital and clinic in Sacaton, Ms. Shannon, Dr. Noel Habib (Chief Medical Officer), Marcy Hamblin (Interim Chief Nursing Officer), and Sarah Wolterman (Risk and Quality Manager) accompanied lead surveyor, Nelson Sirlin, M.D., as he surveyed the hospital and clinic in Sacaton and the clinic in Gila Crossing.

Throughout the first day, Dr. Sirlin quizzed GRHC staff on processes and systems in our specific areas of assignment. Dr. Leonard Sanders demonstrated to Dr. Sirlin the recently installed electronic health record (EHR) system, which greatly enhances medical diagnosis and patient safety via accuracy of record keeping. In the Credentialing Department with Susan George, Dr. Sirlin focused on medical staff documentation and credentialing when he conducted an in-depth review of medical staff files. During the survey at the Gila Crossing Clinic, the Joint Commission performed an intense review of patient identification and patient rights with the lab technicians. Dr. Sirlin had discussions with staff on items such as medication management, provision of care, infection control, human resource preparation, environmental landscape and safety measures, emergency management, National Patient Safety Goals, leadership, and governance of the organization. Interviews were also conducted emphasizing the standards for information management which included information technology and health information management and performance improvement.

On the third day of the survey, Clayton Harvey (Facilities Manager) and Pam Thompson (Chief Operations Officer) accompanied engineer surveyor Mark Trudzinski, CHFM. As he was conducting the building tour, Mr. Trudzinski, an experienced surveyor of over 100 healthcare facilities and hospitals in the areas of environment of care and emergency management, told GRHC staff, “You do an awesome job here. What we look for is a culture of safety, and you clearly have one here.”

Dr. Sirlin has been with the Joint Commission ten years and has surveyed numerous American Indian hospitals and clinics. In closing remarks, the two surveyors praised the organization for its commitment to providing quality care on an ongoing basis. Dr. Sirlin declared, “It is essential that a safe, quality-driven organization hire, support, and retain only the very best staff that not only share the commitment of the organization but are also active participants…. Take the time to celebrate and be proud. This organization has accomplished a great survey, and it is easy to see the caring that takes place here. The most important factor is the people who make it happen each and every day. My question is, ‘Where do you find these good people?’”

Though two minor recommendations for improvement were noted by the Joint Commission and immediately corrected by staff, the surveyors had no recommendations that required formal correction, a feat the surveyors were quick to point out. “This is the best report I have ever experienced in my ten years as a surveyor,” stated Dr. Sirlin. “This community is incredibly lucky to have an organization like this. They need to know that you have been measured with the same standards used to measure Harvard and Yale and the likes. You need to be sure that your community knows that you measure up. I’ve surveyed a lot of Indian facilities, but I had no idea a place like this existed.”

GRHC’s CEO Hugh Collins spoke of his pride in staff whose commitment made the difference. To celebrate, an ice cream social was held a few days after the strenuous three-day survey and was truly enjoyed by all.