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One year later, hospital is still busy gathering data

Accreditation Connection, May 28, 2007

For anyone who thinks the accreditation process gets easy after the unannounced survey is over, think again. Since having its first unannounced survey in May 2006, Huntington Hospital in Pasadena, CA, has been as busy as ever in dealing with overturning RFIs, handling evidence of standards compliance (ESC), and collecting data and submitting reports for measures of success (MOS).

That doesn't even include all of the work that's gone into finishing the hospital's PPR and keeping staff members motivated to ensure compliance without the threat of a survey. "The survey ended, and we just went back to work making sure everything was in order," says Marty Waskul, project manager at Huntington, a 522-bed community hospital. "We put a heavy focus on adjusting policies, changing forms, and educating staff based off what we learned during the survey."

The entire ESC process took the hospital from May to November 2006 to maintain compliance with the six RFIs the hospital received and complete the MOS report, after which staff members went directly to work on the PPR, using many of the same tools, self assessments, and grading processes the hospital used to prepare for the actual survey, Waskul says. "The six RFIs were all on the top 2006 challenging standards list, so they aren't easy problems to fix. We wanted to make sure the solutions were ones that would actually work and not just plug a gap."

Access the full story in the May issue of Briefings on The Joint Commission; access is free for subscribers, nonsubscribers can sign up for a 30-day free trial of BOJExtra! or purchase a copy of the story for $10 by clicking here.

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