Accreditation

On November 16 and 17 Mendocino Coast District Hospital underwent our eagerly awaited Joint Commission on Accreditation of Healthcare Organizations survey. The Joint Commission (TJC) is a National organization, created by the American Hospital Associaton, the American Medical Associationsent and the American College of Physicians nearly 60 years ago. It surveys over 17,000 health care organizations and programs in the United States. The Joint Commission's number 1 priority is patient safety. We were visited by 3 surveyors. 1 surveyor was dedicated to Life Safety Code compliance. He was here for the first day only. The other 2 surveyors included a Team Leader (who was a former critical access hospital CEO) and a Home Health surveyor. They were here for 2 days. Our staff described this year's survey as a very positive experience, in which surveyors collaborated with our staff to improve our patient care delivery systems. A written report of the survey was received on November 24. It documented that MCDH did very well during they survey and has relatively few corrective actions to take. During the 2-day process, surveyors commented many times during the time that they were here of how many “best practices” they discovered here. Some of the best practices included sample medication storage at NCFHC, our Guided Imagery CDs in surgery and our anti coagulation clinic to mention a few. Our staff did a great job. Susan Bivins, in particular, is to be commended for an excellent job of preparation.

It is very rare that one has the opportunity to experience a hospital accreditation survey and also meet the President of The Joint Commission in the same week. I had that privilege last week. After going through the survey process for 2 days in Fort Bragg, California on Monday and Tuesday, I attended an American Hospital Association Board of Directors meeting on Thursday and Friday in Chicago, IL. Our first speaker on Thursday morning was Dr. Mark Chassin, President of The Joint Commission. Dr. Chassin gave us an overview of recent changes made by TJC and demonstrated how accredited hospitals, on average, perform better on safety measures than when compared to all hospitals in the United States. I was particularly struck by his comments on Joint Commission's new Mission Statement and new emphasis on "evaluating and inspiring" hospital professionals during the survey process. I was proud to be able to inform Dr. Chassin that his survey team that visited MCDH last week, truly did evaluate and inspire us. I am also proud to be a part of a hospital that lives up to the Joint Commission standards.