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The Long Wait
When the Joint Commission finally arrived during one of the last weeks of the year, Hopkins Hospital was ready.

blank Katie Bell
Sue Franklin advocates continuous readiness for surveys.

Susan Franklin had grown tired of the drill. At 6:30 a.m. nearly every Monday since January 2007, Hopkins Hospital’s regulatory affairs director arrived at a command center in the Billings Administration Building to find out if the Joint Commission would be on campus that week for a full accreditation survey. With lumps in their throats, she and her team would wait for the morning phone call announcing surveyors were there.

For more than 11 months, that call—and the adrenaline rush that follows it—never came. But when the Joint Commission finally did arrive during the week of Dec. 10, the hospital was ready. Hopkins emerged from the tense week with its full accreditation intact.

The commission’s surveyors evaluate an institution’s compliance with more than 250 standards, many of which involve quality and safety. If they flunk the hospital on a standard, they give it an RFI—requirement for improvement—too many of which can result in conditional or denied accreditation. A hospital could receive an RFI if, for example, a surveyor spied a nurse giving a medication without properly confirming the patient’s identification, or if a surgical team failed to conduct and document a timeout before a procedure. As a large hospital, Hopkins needed less than 13 RFIs to maintain its full, unconditional accreditation. It ended up with seven.
“I think we did spectacularly well,” says Karen Haller, the hospital’s vice president of nursing and patient care. “We ought to feel that the patient safety work we’ve done has paid off. Seven RFIs is exceptionally good performance. We’ve heard that normal is somewhere between nine and 11.”

Though Franklin described the waiting experience as somewhat “numbing,” she says the extra time gave the hospital a chance to educate staff on standards compliance, fine-tune policies and audit caregiver practice.

What did the surveyors find fault with? Among the RFIs were unlabeled syringes on anesthesia carts, expired and unsecured medications on these carts, blocked exit doors and other life/safety violations, pre-procedural history and physical exams that were more than 30 days old, inconsistent implementation of policies and procedures and incomplete documentation.

It was the hospital’s first full Joint Commission check-up since 2004, and the first since the influential agency went to unannounced visits. Now that this much-anticipated survey is complete, Franklin and Haller want to shift the hospital to a new mode—continuous readiness—because the date of the next visit will be even more unpredictable. While they knew that the most recent visit would occur sometime in 2007, the hospital’s next full accreditation survey will be anywhere between 18 and 39 months from now..

“They won’t come before June 2009,” says Franklin, “but beyond that, we know nothing.”

—Jamie Manfuso



Johns Hopkins Medicine

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