But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Monday, October 4, 2010

Joint Commission Report

Representatives from the Joint Commission visited us last week for their periodic survey. I post below today's email from me to our staff. As noted, the actual report is available for all to see. We view that as an essential way to make sure all people here can benefit from this appraisal of our clinical quality.

Beyond the report and the email below, I want to mention an important item for your consideration. Many readers here will recall our dedication to transparency about a wrong-side surgery event several years ago. With full staff participation, we then devised a new pre-surgical protocol.

During this survey, this protocol was viewed in actual surgical settings by one of the surveyors, who said, "That is the finest time-out I’ve ever seen." The JC surveyors said they would recommend it as a "best practice" to be shared with other hospitals throughout the country.

I view this as yet another validation of the use of transparency to help obtain process improvement.

Here's the email:

As many of you know, we recently had a visit from the Joint Commission, the organization that accredits all of the hospitals in America. The surveyors from the Joint Commission spent several days here in intense review of our physical facilities, our information systems, and -- most importantly -- our actual delivery of care to patients.

As is the current practice, this was an unannounced visit, with the surveyors showing up on a Monday morning with just a few hours notice. The people who came were excellent, thoughtful, and comprehensive. There were six surveyors who spent a total of 24 surveyors days with us. In all, they talked with almost 300 of our staff members and visited 49 unique sites on and off campus.

They found some things that needed improvement, but they also had many compliments for the hospital in general and for many, many of you in particular.

My favorite quotes from them during the week were, “The team is impressive – it’s a privilege to be a witness to the care being provided;” and "They are completely committed to what they do -- inspirational."

Consistent with our practice, we want you to have the advantage of their work product, so we have posted it on our website. Please read it.

With gratitude and appreciation,


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