June 20, 2003

Accreditation team will visit Vanderbilt June 23-27

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Accreditation team will visit Vanderbilt June 23-27

As happens every three years, next week a team of inspectors from the Joint Commission on Accreditation of Healthcare Organizations will be observing activity and talking with staff and faculty throughout the hospital and clinic and VUMC satellite locations across Tennessee.

Vanderbilt’s accreditation as a health care provider is based on the results of this inspection. The team from JCAHO will be on campus June 23-27.

JCAHO doesn’t call it an inspection; they call it a survey, a gentler label implying that the accreditor is the partner of the accreditee in helping to ensure health care quality and safety.

Sue Moseley, director of accreditation and standards for VUMC, says JCAHO has continued to redesign its inspections to focus on more meaningful measures of quality and safety.

Overall results of the inspection, including any citations for lack of compliance, are published on the commission’s Web site.

Moseley offers some tips for staff and faculty interacting with JCAHO inspectors: If you don’t understand what an inspector is asking, ask him or her to clarify the question before attempting to answer. Also, feel free to speak up if you notice that a colleague is leaving out anything important when addressing an inspector’s question; it’s all right for others to join in answering any question addressed to any colleague.

Unlike previous surveys, this time surveyors will extend their work to include one evening shift (Moseley said unit/clinic managers should be prepared to come back to work to assist surveyors). JCAHO is phasing out scheduled surveys; all future VUMC surveys will be unannounced.

A year ago the commission announced six national safety goals as a major new focus of the 2003 inspections. The commission also issued 11 recommendations for meeting the goals. The safety goals and recommendations, which impact VUMC direct patient care roles and some ancillary roles such as patient transport, have been among Vanderbilt’s top priorities. A broad assortment of VUMC groups studied the goals and recommendations and advised decision makers regarding new policies and procedures needed to address them. The changes were implemented at VUMC over the winter and spring.

Beyond the new safety recommendations, other priorities for JCAHO inspectors include infection control practices, patient screenings (functional health, nutrition, pain, preferences for patient education, etc.), use of patient restraints and completion of the patient’s problem list.