February 17, 2004

John Dempsey Hospital Wins Reaccreditation

The John Dempsey Hospital has been reaccredited for three years by the Joint Commission on Accreditation of Healthcare Organizations.

JCAHO is a private, non-profit organization from Oakbrook Terrace, Ill., charged by Congress with evaluating and accrediting health care organizations in the United States. Reaccreditation is a nationally recognized "seal of approval" demonstrating that the hospital meets certain performance standards.

Dempsey Hospital was evaluated in two categories: behavioral health care - the psychiatry partial hospital program - where it earned a score of 97 out of 100; and hospital services, which included inpatient units, the emergency department, and outpatient clinics under the purview of the hospital, such as cardio-pulmonary services, the Comprehensive Cancer Center, and outpatient psychiatry, which received a score of 93.

Rhea Sanford, director of performance improvement and patient safety and chair of the committee that did the preparation for the survey, said the reaccreditation process went well. "There were two reasons," she said. "One is the hospital was very well prepared. The second is that we had a very professional survey team that was entirely focused on the standards."

Preparation for the survey involved detailed planning. A committee with 17 members, including nurses, administrators, and pharmacists representing all units and departments to be surveyed, met regularly and pored over the hundreds of pages of standards. They also conducted mock surveys on the units.

The team that surveyed Dempsey Hospital consisted of a physician, a nurse, and a hospital administrator. Another inspector conducted the behavioral health survey.

The inspection - JCAHO prefers the term "survey" - lasts three or four days. It consists of a team making a site visit and assessing how the organization's performance in key areas - such as patient rights, patient safety, patient treatment, and infection control - meets standards.

During the survey, team members visit units and meet with clinical staff, physicians, and managers - the people who provide direct care.

Surveyors identify a case and look at everything on that patient's treatment plan. Then they assess whether the care delivered meets Joint Commission standards.

In addition to patient safety and security, surveyors assess how a hospital handles life safety, medical equipment, utility systems management, hazardous materials and waste management.

The surveyors also assess compliance over time.

Besides leading to improvements in patient care, JCAHO surveys demonstrate an organization's commitment to safety and quality; support and enhance safety and quality improvement efforts; and certify the level of care is appropriate for Medicare and Medicaid reimbursement and other third parties.

"The survey results are a reflection of the care we give," said Jeanne Lattanzio, director of nursing. "There are things you can do to prepare, but in the end, it's the quality of care you deliver on a daily basis that's being surveyed."

In the future, JCAHO surveys will be unannounced.

"Being prepared starts with understanding the standards and then putting programs in place to achieve not only compliance, but the added benefits of a safe and cost effective operation," said Daniel J. Penney, assistant vice president for facilities management and the hospital's safety officer. "Since future surveys will be unannounced, maintaining a state of full compliance at all times is critical."

Dr. Steven Strongwater, director of clinical operations and hospital director, said the JCAHO site visitors made positive comments about the Hospital's staff and programs: "The hard work everyone at JDH does every day was recognized."