Joint Commission Survey Results

Monday, April 08, 2013 at 2:22:30 PM

The recent Joint Commission survey included 29 surveyor days over 2 hospitals and 27 practice locations. The results were very good with positive comments on the culture of safety and team work present. The surveyor was very impressed when 22 members of Medical Executive Committee came to meet with him at very short notice demonstrating the engagement of the Medical Staff.

Despite the positive overall impression, there are still some plans of correction and monitoring to be done. Dating and signing of phone orders within 48 hours was found to be lacking, as was dating and timing in general of notes and orders. Post-procedure notes need to be done immediately with comment on blood loss. Histories and physicals were found more than 30 days old and not updated prior to procedure. Illegibility of notes and signatures was found in many areas and will be a focus of activities going forward. Your continued diligence in these areas would be helpful

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