MAY 2011 EDITION
EMPLOYEE NEWSLETTER HOSPITAL | SENIOR CARE CENTER | FOUNDATION
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GOING FOR THE GOLD Gunnison Valley Hospital Seeks Joint Commission Gold Seal of Approval On March 23 and 24th Gunnison Valley Hospital underwent a two day intensive review by two surveyors from The Joint Commission. They evaluated both the safety of the building and equipment and the safety and quality of patient care. Both have vast experience and credentials as practitioners of their professions, in addition to surveying hospitals. Dr. Amir Ansari is a practicing Hematologist with over 30 years of experience, and Mr. Peter Jaroscak is a certified Fire Fighter, Fire Inspector, and was the Director of Safety Betsy Blair and Security at his hospital for 23 years. Chief Operating Officer GVH has chosen to become Joint Gunnison Valley Health Commission accredited, even though most patients (customers) don’t know what it is. Dr. John Tarr notes that inspection by an outside agency prevents us from becoming complacent, since we may not be able to see our own deficiencies. Many of the JC standards are also conditions of participation in Medicare, and much of the Hospital’s reimbursement and our State licensure are contingent upon compliance. In addition, the surveyors visit many hospitals and share best practices with us through consultation with staff and Leadership. As an example, Dr. Ansari demonstrated how our infant security system could be easily disabled by someone wanting to steal a baby. Over the past 10 years, the JC has emphasized Patient Safety by promoting evidence based safety practices like time outs before surgical procedures, hand washing, labeling medications, medication reconciliation, falls prevention, and others. These practices have been proven to reduce wrong site surgeries, life threatening infections, and deadly medication errors. During the Leadership Interview, Dr. Sherry Niccoli, Chief of Staff said “There is a changing paradigm of how physicians think about their patients: we need to recognize that it is a team effort versus the captain of the ship. We all need to work together to help keep our patients safe.” Carol Kennedy, Chief Nursing Officer continues to remind us that Joint Commission Accreditation should be considered minimal compliance and that we must strive for excellence above and beyond what is required by regulations. As a result of the survey, the surveyors found several areas of noncompliance, some of which relate to building safety and some to patient care. The Hospital must submit evidence of actions taken to correct the deficiencies within 45 to 60 days, depending on the standard. Once
BUILDING SAFETY DEFICIENCIES INCLUDE: I I I I
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Unsecured medical gas tanks, which can become missiles if they fall over and damage the outlet fittings. Uncovered electrical junction boxes posing electrocution and fire risk. Deficient documentary proof that the emergency generators and transfer switches work. Several of the fire dampers that prevent spread of smoke and fire through the heating and ventilation system hadn’t been tested in the last 6 years, and some were even not accessible behind walls and ceilings. Parts of the fire sprinkler system hadn’t been tested, and couldn’t due to inadequate drains to allow such testing.
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Some fire extinguishers hadn’t been checked.
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The fireplace in the lobby could burn anybody touching it.
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The Medical Gas Storage Room didn’t have a sign to inform the Fire Department in case of emergency. Some fire extinguishers in the lab were mounted too high or behind other equipment, making them hard to reach.
UNSAFE PATIENT CARE CONDITIONS FOUND INCLUDED: I
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Several unsafe abbreviations. Despite the fact that, upon further review, the percentage did not necessitate formal GVH response, patient safety is still at risk. Many medication orders were incomplete, not listing doses, frequencies, routes, etc. The Pre-Anesthesia evaluation had not been properly documented prior to the patient going to surgery in two cases. The containers of Steris Strips used to verify proper sterilization of surgical equipment were not dated at opening, making it impossible to verify that the equipment was adequately sterilized between patients. Ongoing review and supervision of CRNA performance could not be documented.
these corrections are completed and approved by the JC accrediting board, GVH will receive 3 years of full accreditation. The next Joint Commission unannounced survey can occur anywhere between 18 and 36 months following this recent survey. Dr. Ansari noted that this is a particularly short list of deficiencies and complimented the Hospital on many areas of exceptional patient care and sound practice. He was very impressed with the work that had been done in the area of Emergency Preparedness under the leadership of the EM Team Please see GOLD on page 2
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