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Joint Commission Survey Results Are In!

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Last month, BWFH had a four day visit from the Joint Commission, the independent, not-for-profit organization that accredits and certifies healthcare organizations and programs in the United States.  Over the course of their visit, a team of 5 surveyors inspected and toured nearly every area of the hospital, spoke to dozens of staff members and reviewed numerous patient charts and employee files. Collectively this translated to 104 hours of surveyed time!

“During our surveyor wrap up session,we had a good feeling that the results of the survey would be overwhelming positive,” states Christi Barney, RN, MSN, Executive Director of Clinical Compliance.  “Now that we have our official report I can say for certainty that this was the most positive Joint Commission survey I’ve been part of.”

While there were findings that will need to be addressed with some corrective action planning in the next 60 days, there were no significant findings that would trigger another survey until our three year window reopens in 2023. 

Among the areas that Barney suggests keeping a close eye on are:

  1. All areas should review and complete logs, particularly code cart and eye wash.
  2. Continue to keep hallways clear and be mindful of the height of stored items near sprinkler heads in storage areas.  Specifically, do not place items on top of linen carts.
  3. Clinical teams should review materials you have regarding suicide assessment of patients and verify that you understand the updated policy on suicidal patient reassessment. 
  4. In all areas where procedures are performed, ensure that we are demonstrating our use of appropriately marked areas/containers (biohazard) for soiled instruments, and are using spray.
  5. Any area where paper signatures are obtained for consents or any patient process, remember to sign, date AND TIME both patient and staff signatures.  This is a CMS requirement.

“Perhaps one of the most positive aspects of the survey was that each surveyor went out of their way during their visit to tell us how impressed they were with the cleanliness of the building, the attention to our surgical instrument cleaning, our outreach to the community, our mission to educate, our attention to the emotional health of our staff, our innovation in addiction treatment, the fantastic food and the extraordinary kindness and enthusiasm of our staff,” continues Barney.  “And they certainly noticed how actively we work to create a safe environment for our patients, visitors and each other in every inpatient and ambulatory practice throughout our facility.” 

In fact, some of the processes and innovative ideas they witnessed, especially around our COVID-19 surge planning, are being brought back as best practices to share with other institutions across the country.

“While this survey is a validation of the exceptional care we provide here at the Faulkner, it’s really about how each and every person plays a role in taking care of our patients and visitors,” continues Barney. “Without the extraordinary dedication that each staff member displays, a positive survey of this magnitude is simply not possible.”

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