Dr. Mark A. Magnuson uses genetically engineered mice to study the enzyme glucokinase. (Dean Dixon)
VUMC earns its highest score from accreditors
If preliminary results hold, this year VUMC will achieve its highest score ever for the triennial survey conducted by the national health care accreditation authority, the Joint Commission on Accreditation of Healthcare Organizations.
A team from JCAHO was on campus June 23 – 27 to examine records, observe activity and facilities both on and off campus, and talk with staff, faculty and patients.
Surveyors gave VUMC a preliminary score of 90 out of a possible 100. Vanderbilt’s preliminary score from its 2000 survey was 89, and its score in 1997 was 86. JCAHO will issue final findings from the survey within nine months.
“The survey team’s very positive findings speak to the great attention to quality and safety practiced by staff and faculty here at Vanderbilt,” said Norman Urmy, executive vice-president for clinical affairs and CEO of VUH. “Particularly in an organization of our size and complexity, there is no way to score a 90 from JCAHO without the concerted efforts of the entire staff. The survey team was extremely complimentary. They found a staff that worked well together and that communicates well as a patient care team.”
The vast majority of hospitals in the survey receive from one to four “type one” violations that require correction and formal follow-up to accreditors. VUMC received three type one’s in the recent survey; the survey team discovered (1) instances in which controlled substances were not properly stored, (2) in an audit of randomly drawn personnel files, a file in which training, orientation and competency assessment weren’t documented as having occurred until three months after the start of employment, and (3) a personnel file that indicated that a temporary nurse on one unit was not reassessed for competency upon being reengaged for work after a year’s absence from the unit.
These violations are of a different cast than those of three years ago, when VUMC was cited with seven violations for more pervasive problems that required major organizational efforts to fix, from documentation of living wills, to maintenance of the patient problem list, to use of restraints, to initial patient assessment for nutrition and for functional status.
“We now have a lot of processes in place that support continuous compliance,” said Susan Moseley, director of Accreditation and Standards. “We’ve made many, many improvements in our patient care documentation systems. And everyone has given detailed attention to the findings from the last survey; we stayed on top of the things they found last time, and it showed.”
Overall results of the survey are published on the commission’s Web site. After 2003, JCAHO will no longer announce its surveys. VUMC will submit a self assessment in 18 months, and the next on-site survey will occur unannounced sometime in the latter half of 2005 or the first half of 2006.