A Job Well Done: Joint Commission Visit to NCH

The Joint Commission recently made a visit to Northwest Community Hospital (NCH), bringing with it a team of certified surveyors who performed a rigorous evaluation of NCH’s facilities, technologies, safety measures and patient care processes. The Joint Commission’s on-site survey – conducted every three years – is a critical step in the accreditation process for medical facilities seeking to earn or maintain the Gold Seal of Approval™.

Both the Hospital setting and NCH Home Healthcare program were evaluated by the Joint Commission for compliance with standards of care, infection prevention and control, leadership, and medication management. According to Cindy Dougherty, director of Quality Measurement & Improvement at NCH, the on-site visit was an overall success.

“The surveyors were thoroughly impressed with the high level of care and collaboration seen among clinicians and doctors in the patient care settings,” says Dougherty. “We want to especially thank the medical staff for their time, expertise and support throughout the entire accreditation process. A job well done!”

Opportunities for Improvement
While the Hospital left a good impression with the Joint Commission, the survey revealed specific areas in which improvements could be made. In an effort to achieve and/or exceed compliance measures set forth by the Joint Commission and the Centers for Medicare and Medicaid Services (CMS), please take note of the following updates and reminders:

• [NEW] History and Physical Update Note Form – The CMS is now requiring doctors to use specific language in the History and Physical Update Note indicating that a patient has been examined prior to a procedure or surgery. To help doctors adopt this new requirement, NCH has introduced a new History and Physical Update Note Form that includes the appropriate language now required for documentation. The form is available on the nursing units, in Surgical Services and the Day Surgery Center.
• Documenting Date and Time – When documenting in a patient’s medical record, CMS requires that doctors record both the date and the time of entry.
• Authenticating Orders – Depending upon the origination of the order, authentication can be done via the patient's chart when the doctor arrives to the unit, or electronically through CareLink Portal.
• Post-Procedure Note – Any time a procedure is performed at NCH, regardless of the location (e.g., the Operating Room, Cardiac Cath Lab, or Interventional Radiology), the doctor is required to write an immediate Post-Procedure Note. According to the Medical Staff Rules and Regulations, the Post-Procedure Note should indicate:
  • Who preformed the procedure
  • Type of procedure performed
  • Findings of the procedure
  • Final post-procedure diagnosis
  • Specimens obtained
  • Estimated blood loss
    * when applicable, zero blood loss must be documented and not left blank

“The Joint Commission surveyors reminded us that the site visit, in part, is intended to inspire the Hospital through its journey in quality,” says Dougherty. “By addressing these areas of need, our goal is to raise quality performance at NCH, ultimately impacting patient care and creating an even better environment for doctors to practice.”