During the week of June 25, AAMC held a Joint Commission mock survey. We periodically stage a mock survey to assess our readiness and compliance with 2012 Joint Commission Accreditation Standards. The mock survey operates the same way a real survey would, with surveyors observing and interviewing staff and conducting patient and system tracers. They help us identify gaps in issues related to patient safety and quality and provide counsel to leadership, physicians and staff. Overall, we did well. Here are highlights of our mock survey strengths and opportunities:
Staff, physicians and leadership were very engaged. Surveyors valued our High Quality, Low Cost initiatives.
Surveyors applauded the availability of bilingual forms, as well as the patient/family status boards in the OR. There were instances were documentation wasn’t completed for educating around advance directives, care coordination, patient education. In addition, the surveyors found instances of inconsistent and missing documentation.
- Infection Control: There was inconsistent use of personal protective equipment, germicidal wipes and hand hygiene.
The surveyors were impressed with the Facilities team as well as the ED physical space and processes. Our pediatric security systems are strong.
- Environment of Care: Equipment was found blocking electrical panels and gas valves. There was clutter in hallways and fire doors propped open.
Staff lacked knowledge of how to clean durable medical equipment, how equipment is maintained by BioMed and how to turn off a gas valve.
- Medications and Supplies: Unsecured medications were found on the floors. There were instances when staff didn’t know what a product on the unit was or how to call in MSDS.
- Medication Management: Surveyors found the medication management team strong. Physician reconciliation was found inconsistently completed and is ultimately responsible for the accurate reconciliation.