ACH receives Joint Commission accreditation

Published 7:26 am Monday, August 13, 2007

By By Adam Prestridge
Atmore Community Hospital may not be located in a large metropolitan area, but time and time again, its staff has proven to provide the same quality healthcare and personal service and has gained national and state recognition.
Last week, Amir Ansari, an evaluator with the Joint Commission, the nation's predominant standards setting and accrediting body in health care, performed a two-day intensive survey of the hospital. Following his examination of the hospital's policies and procedures, mainly the employees' knowledge of those standards, he presented ACH with its Joint Commission full accreditation.
"The Joint Commission is the most widely recognized accrediting body in the health care industry," ACH administrator Bob Gowing said. "We've been accredited since before my time here and have continued with full accreditation since. What this did was affirm for me that what we're doing here at Atmore Community Hospital from patient quality, patient safety, employee safety and service, whatever measurements you want to look at, that we're doing a very good job. The staff is responsible for it happening."
Gowing said the hospital pays for the Joint Commission survey and the process used to obtain the "stamp of approval."
"This is a voluntary process that we put ourselves through to give our public the insurance that the care provided here is quality care and has oversight by professionals other than our hospital staff and doctors," he said. "There is a third party out there looking over our shoulders and giving you that seal of accreditation that you are doing things like you should be doing."
Amanda Strawbridge, director of performance improvement, is pleased with the survey's results and proud of the staff at ACH for being knowledgeable in hospital policies and procedures.
"I feel very good about the staff and I'm glad it's done," she said. "The staff works really, really hard and they're very open to whatever I take to them even though a lot of times it's more work for them, but they ultimately know that it's for the safety of our patients."
The Joint Commission is governed by a 29-member board of commissioners made up of physicians, administrators, nurses, employers, a labor representative, heal plan leaders, quality experts, ethicists, a consumer advocate and educators. The Joint Commissions mission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.
"It is a stamp of approval, an affirmation of your quality that we want and will continue to do," Gowing said. "It probably costs us more to be accredited, not just the Joint Commission expenses, but the things that they require us to have from a quality standards standpoint than if we weren't accredited. But it also gives the public assurance that what we're doing here at Atmore Community Hospital is meeting a standard that is recognized in the healthcare industry."
Gowing said ACH's last evaluation was in Oct. 2004. This was the second time the hospital had been evaluated using the Tracer methodology where the Joint Commission's evaluator follows actual patients' experiences at the hospital by randomly picking charts.
Last week's evaluation was not scheduled; it was a surprise visit, which was recently adopted by the Joint Commission.
"That's the way it should be," Gowing said. "We should not have the opportunity to prepare. When you think of that, what we do, day in and day out is what they should be surveying, not just how well we prepared over the last 90 days to get our stuff in order. You could get your policies and procedures in better shape than you would probably on a normal day-to-day basis."
During the survey, the evaluator visited the various departments including the emergency room, radiology, the laboratory, pharmaceuticals and even patients' rooms that the randomly selected patients may have visited. Along the way, he questioned hospital staff on how the situation the particular patient was dealing with should be handled and what policies and procedures needed to be used.
"They don't look as much at the policies and procedures, they want to hear what the staff has to say," Strawbridge said. "Your policies can say anything, but they want to know that the staff is practicing those policies."
The new method was not received well when it was first implemented, but Gowing said the system has caught on.
"We did not like it when it was first going to be changed to this method because we were getting accustomed to how we could do well previously," he said.
The hospital was issued a few RFI (requirements for improvement) challenges following the survey. Gowing said the RFIs mainly dealt with hospital facility safety. If a hospital receives too many RFIs they do not receive accreditation.
"In my opinion, this is the right thing to do," Gowing said.

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