FH Survey Overview

Joint Commission 3-year survey summary.

Two Joint Commission (JC) surveyors visited Falmouth Hospital in February 2011 for its routine 3-year survey and renewed the hospital’s accreditation. The surveyors spent a week at the hospital and gave it a glowing report. In fact, hospital Chief Operating Officer Sue Wing said it was the best JC report in her 40 years at the facility.

The two JC surveyors, who have been evaluating hospitals for more than 20 years, spoke highly of the culture of safety, caring, accountability and ownership, said FH Director of Quality Improvement Pamela Kendrick.

“They showed us a graph that showed priority focus areas that hospitals need to be successful organizations, and the chart (for FH) was all green (meaning most areas had been successfully achieved),” Pamela said. “The surveyors said, ‘you just don’t see this (kind of result) with most hospitals.’”

The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, has accredited hospitals for more than 50 years. Today, it evaluates more than 4,250 hospitals – about 88 percent – in the U.S.

The benefits of accreditation are:

  • Strengthens community confidence in the quality and safety of care and services.
  • Helps organize and strengthen patient safety efforts.
  • Provides education on good practices to improve business operations.
  • Provides deeming authority for Medicare certification.
  • Recognized by insurers and third parties.

Among the specific areas the JC looks at in their surveys are the environment of care, infection prevention and control, medication management, record of care, treatment and services, nursing and leadership.

One of the main reasons FH had such a good survey has to do with the adoption of many process improvement initiatives over the last two years, said Pamela.

“I definitely think it was our culture. In the last couple years, we have formalized process improvement and it’s now becoming hardwired,” she said. “It’s the people at the bedside who make the difference.”

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