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A Note from David Entwistle & Tom Miller on the Upcoming Joint Commission Visit

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Jun 29, 2010 1:00 AM

Chief Executive Officer David Entwistle and Chief Medical Officer Tom Miller, M.D., talk about quality and safety and the upcoming Joint Commission accreditation visit.

Six Hot Topics for Joint Commission Survey: Tips from Carol Hadlock, Director of Quality and Patient Safety 1. Record the date and time on all handwritten medical record entries. 2. Perform a history and physical within 24 hours of an inpatient admission and place in chart before a procedure. 3. Complete temperature and crash cart logs daily and documenting the action taken if the temperature is out of the accepted range.

4. Label the syringe with the medication name, strength, quantity, diluent, and volume; writing the expiration date and time if it is not administered immediately. 5. Have Joint Commission readiness cards in place. 6. Make sure there are no expired medications, supplies, and strips in patient care areas.

We sat down with University of Utah Hospitals & Clinics CEO David Entwistle and CMO Tom Miller, M.D., to ask them about the upcoming Joint Commission accreditation visit. Some may feel that a visit from The Joint Commission is as enjoyable as an audit from the IRS and equate their manual of guidelines to the tax code, but Entwistle and Miller shed light on how the accreditation visit is a great opportunity for the organization.

PULSE: Why is The Joint Commission visit important?

Entwistle: The Joint Commission is a key agency that holds hospitals around the nation to universal quality standards. They visit every three years to make sure we’re meeting the bar, and this is an opportunity for us to demonstrate the rigor of our processes and the safety of our workspaces. 

Miller: It’s important to note that The Joint Commission represents the minimum standards of quality that an organization should meet. Because our quality efforts are far and above the minimum, we have set our sights on not just meeting but exceeding the Joint Commission standards. 

Entwistle: I agree—preparing for the accreditation visit is just one piece in a comprehensive quality effort under way here at UUHC. We are driving quality through keen attention to our core quality measures and specific activities in our critical care and other environments that make a difference in the lives of patients.

PULSE: What type of motivational message would you like to share with staff and physicians?

Entwistle: I am impressed on a daily basis by the quality of care our staff provides, and this is everyone’s opportunity to be recognized for their work. Our staff should feel confident about the accreditation visit; we know the material and can pass the test.

Miller: I’d like to encourage all physicians to present a positive attitude during the visit. I understand that it may be inconvenient to be stopped in the middle of a day of patient care to be quizzed on our activities, but as medical staff we need to be just as responsive as nurses and environmental services staff. What’s more, physician participation demonstrates for the surveyors and our staff just how integrated our care teams can be.

PULSE: How can staff balance their daily patient care delivery with preparing for The Joint Commission visit?

Entwistle: I don’t think these two things are at odds. We meet these standards every day in our practice, and staff simply need to pay attention to their managers to brush up on the finer points that surveyors may ask during their visit. We are lucky to have a great Quality and Patient Safety department working around the clock to provide training in all of the right areas. 

Miller: Just as David pointed out, no one needs to know the entire Joint Commission manual, just the critical points for your area. On the physician side, I’ll be mobilizing a new structure this year: I have 89 medical directors who will bring salient information to physicians in their areas. All in all, we’ve got an excellent environment, an efficient way to communicate knowledge, and an amazing group of employees and physicians.


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