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Patient safety, med management, and communication comprised majority of hospital's recent survey

Accreditation Connection, August 13, 2007

During Northwestern Memorial Hospital's five-day unannounced survey this past spring, surveyors performed nearly 20 tracers with a focus on assessing care/services, communication, staffing, patient safety, and orientation and training.

Although The Joint Commission surveyors closely followed the process outlined in the Survey Activity Guide (SAG), the survey still presented challenges and plenty of stress for the 744-bed hospital, according to Jodi Eisenberg, MHA, CPMSM, CPHQ, program manager of accreditation and clinical compliance at the Chicago hospital.

The hospital's final report from The Joint Commission contained fewer than 10 RFIs, but that was after the facility prepared and submitted clarifications to The Joint Commission to get three RFIs overturned-prohibited abbreviations, verbal order read-back, and a minor environment of care (EOC) issue. Because the RFIs were on C-scored standards, Eisenberg and her team were able to get them overturned by providing data from a larger sample, something that she recommends every hospital do if it gets cited on C-scored standards.

Access the full story in the August 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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