"The Ronan Report" provides insight about the activities at the Western Maryland Health System in Cumberland, Maryland, and about the changes taking place in healthcare today from a CEO's perspective.

Wednesday, May 29, 2013

Lessons from the Joint Commission

As I blogged yesterday, the Joint Commission conducted their three-year accreditation survey last week.  It was a very good experience.  This was my thirteenth survey during my career and it is amazing as to how things have changed over thirty eight years.  My first survey was very different from last week's survey.  That survey focused on the negative; the Joint Commission has standards and you had better be in compliance.  Then, if you weren't, you had to hear about it from the Joint Commission surveyors as well as at a department directors meeting in front of everyone else.  None of it was fun. 

Rolling forward to last week, the survey was very consultative as has been the case with the last several.  We were concerned that the "thoroughness" of one of the surveyors would be a problem, but in the end the lead surveyor took control and the survey was both helpful and at the same time a validation of the hard work that goes on at WMHS to ensure quality care of our patients.  There were a few issues that we will need to bring in line, but overall, we did well.  A lot of people worked very hard in preparation for this survey that was three years in making. 

What I did find interesting is that the surveyors know pretty much on day two of the five day survey as to what the outcome will be.  Obviously, a lot goes into how they are treated as well as the reaction to and acceptance of what the surveyors have to say.  In our case, all went well, but I can see that not being the case all of the time. 

For me, it was another good lesson.  Many years ago, I was involved in a survey where the CEO actually stopped the survey and called the Joint Commission regarding the perceived unfairness of a nurse surveyor. She backed off once the lead surveyor took control of the situation after receiving a call from the home office in Chicago.  That was very interesting as well as so very risky. 

All in all, at WMHS we are done hopefully for another three years although the work for that next survey already has begun.

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