June 2, 2006

JCAHO findings laud VUMC’s level of quality, safety

JCAHO findings laud VUMC’s level of quality, safety

Vanderbilt University Medical Center administrators say they're very pleased with the findings of a recent triennial assessment of the Medical Center and its off-campus facilities by a team from the Joint Commission on Accreditation of Healthcare Organizations.

Arriving unannounced on May 8, the team spent five days following a diverse group of randomly selected patients through the hospital and clinic. In their summary report, they made five binding “recommendations for improvement” regarding information security, medication management and patient safety.

“They told us it's unheard of nowadays for organizations to receive so few recommendations,” said Susan Moseley, director of accreditation and standards for VUMC.

“The summary report and compliments we've received from the JCAHO team speak quite well for the safety and quality of the care provided at VUMC and for the dedication and expertise of our clinical staff and faculty,” said Norman Urmy, executive vice president for Clinical Affairs.

At a recent VUMC management seminar, Steven Gabbe, M.D., dean of the School of Medicine, relayed comments made by the JCAHO team at the conclusion of their visit: We rarely see the level of collaboration we've seen here. I hope you realize what an outstanding report this is … Vanderbilt sets the standard.

“For all of you who worked so hard to make our JCAHO visit a great success, thank you,” Gabbe told the group.

VUMC has 45 days to address the visitors' five recommendations for improvement.

John Doulis, M.D., assistant vice chancellor and chief operations officer of the Informatics Center, and Dan Beauchamp, M.D., chair of the Section of Surgical Sciences, will lead separate teams addressing recommendations about the timeliness, completeness and authentication of various patient information used by surgical and post surgical teams.

Beauchamp will also lead a third group that will address a recommendation concerning an operating room practice called ‘time out,’ where surgical teams pause to run through a check-list before operating.

Jim Jirjis, M.D., assistant professor of Medicine and director of the Adult Primary Care Center, will lead a team to address a recommendation about medication documentation and communication.

The fifth recommendation from JCAHO concerns standardization of the abbreviations used in patient charts. Moseley said this recommendation has already been addressed through an audit of patient charts.