Thirteen surveyors from The Joint Commission (TJC), the independent, not-for-profit organization that accredits and certifies more than 20,500 health care organizations and programs in the United States, visited Vanderbilt University Medical Center last week for an unannounced survey.
TJC visits accredited health care organizations a minimum of once every 39 months (two years for laboratories) to evaluate standards compliance. The commission’s surveyors are doctors, nurses, hospital administrators, laboratory medical technologists and other health care professionals. The Joint Commission is the only health care accrediting body that requires its surveyors be certified.
Although VUMC won’t receive the final accreditation document for a few weeks, the surveyors spoke with Medical Center leadership before they left, and indicated that the Medical Center far exceeded expectations.
C. Wright Pinson, MBA, M.D., deputy vice chancellor for Health Affairs and CEO of the Vanderbilt Health System, joined Marilyn Dubree, MSN, R.N., Executive Chief Nursing Officer, and David Raiford, M.D., chief of staff for the Vanderbilt Health System, earlier this week to pass some of the surveyors’ comments along to an overflowing room of clinical enterprise leadership in Light Hall.
“I don’t know how to convey our thanks to our faculty and staff for the impression that you left with the surveyors,” Pinson said. “We put our best foot forward and the surveyors saw us for who we are.”
About 100 Medical Center staff members served as escorts for the surveyors as they visited 21 clinics and more than 100 areas both on campus and at Vanderbilt Health’s satellite areas throughout Nashville and the surrounding counties.
During the survey, surveyors select patients randomly and use their medical records as a roadmap to evaluate standards compliance.
As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care and often speak to the patients themselves.
Dubree shared some of the surveyors’ comments with the group. “They told us that our staff is eloquent and compassionate, and the patients are happy and thankful,” she said. “They said that VUMC is a world class institution, and that we should package it and send it out to the world,” she said, adding that the surveyors were impressed with the Medical Center’s paired leadership model. “Our strengths are too numerous to detail, and they far outweigh the areas where we need to improve.”
VUMC will now take the recommendations made by The Joint Commission and analyze to determine next steps.
Raiford shared a few opportunities for process improvement with the group. “The spirit of this place carried us through and says a lot about who we are. We are not perfect. We don’t pretend to be. But we aspire to be,” he said.
