Message Archive
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
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