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July 28, 2009

Joint Commission Survey Preparation

Staff throughout the John Dempsey Hospital are preparing for the upcoming accreditation visit by The Joint Commission (TJC) – an independent accrediting organization that surveys 88-percent of hospitals in the United States. The survey is based on specific standards derived from information gathered from healthcare experts and consumers. The standards “address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment.”

TJC will be on site for a four-day unannounced survey anytime from now through December 31, 2009. During the survey, they will inspect all patient care areas of the hospital using a tracer format which follows patients’ progress through various hospital departments. During the tracer survey, they will interview members of the health care team as well as patients and their families. An accreditation survey is valuable to the hospital not only because it is required by CMS and other insurance providers but it also validates the high quality care provided at John Dempsey Hospital.

A “mock tracer program” has been implemented to assure our compliance with TJC standards. Tracer teams, comprised of managerial and clinical staff, not only survey assigned areas but also educate staff members regarding compliance with the standards. This education has resulted in improved compliance with the standards and has developed the staff’s confidence. The hospital’s administrative team has been assigned to input data into Accreditation Manager Plus, which is a computerized system used to indicate compliance with TJC standards. This tool combined with the mock tracer program provides hospital leadership with opportunities for improvement in all areas to be surveyed.

I would like to take this opportunity to thank everyone on the staff of John Dempsey Hospital who works hard every day for the benefit of our patients and their families. I also commend you for the enormous efforts you’ve made to help ensure that we will have a positive outcome to our accreditation survey.

Cato T. Laurencin, M.D., Ph.D.
Vice President for Health Affairs
Dean, School of Medicine