By Mary Jo Shafer, The Anniston Star, Ala.
Jul. 6–Representatives from Anniston’s Northeast Alabama Regional Medical Center will appear before a review panel in Chicago on Thursday to appeal the Joint Commission’s preliminary denial of accreditation of the hospital.
“The key word is preliminary,” said RMC spokeswoman Susan Williamson. “Our goal is to clarify some of the findings and work toward full accreditation.”
The preliminary denial is the result of a series of “requirements for improvement,” identified by the Joint Commission, an independent body that evaluates hospitals nationwide.
The current status is the result of an unannounced survey members of the Joint Commission conducted at the hospital in August 2007.
“Hospitals are surveyed every three years on an unannounced basis,” said Ken Powers, spokesman for the Joint Commission. Teams visit and “look at pretty much everything.” This includes treatment services, the continuum of care, management of medication and information, safety procedures and the physical plant itself, he said. There are more than 200 standards that the teams can look at, he said.
When a preliminary denial happens, there is an appeals process, which can take months, he said.
If the Joint Commission identifies areas as needing improvement, an organization has the opportunity “to submit evidence to clarify, or submit evidence that the findings were inaccurate or show evidence that they were indeed in compliance,” he said.
RMC is currently in the appeals process.
At the review Thursday, RMC will “address how we feel we were in compliance at the time of the survey in some of the areas” the Joint Commission identified as needing improvement, Williamson said “We want to clarify the responses and prove that we actually were in compliance.”
Williamson said accreditation often involves “fluid standards,” which change from year to year. Because of those changes, “you have to adapt your process” to fit, she said.
Accreditation by the Joint Commission is voluntary. “It is a voluntary decision to open themselves up to being evaluated on care and safety,” said Powers. “The purpose of accreditation is for the Joint Commission to work with the organizations to identify areas where they do need improvements and where they are doing well.”
Powers said the Joint Commission surveyed about 4,200 hospitals in 2007. Of those, approximately 1 percent of hospitals undergoing a full survey received a preliminary denial, he said and there were only seven denials of accreditation nationwide.
“It is a very stringent survey, and we have always chosen to participate in it,” said Williamson. “We ask them to come and do this stringent review, and you want them to help you find things and improve in areas you need to improve in.”
“One thing that concerns me is that I don’t want people to think that we aren’t a quality facility because we are,” she said. “These are just things that we need to improve.”
Williamson also pointed to a long list of other accreditations the hospital’s programs has from other agencies, including the hospital’s designation as a Tier 1 hospital by Blue Cross Blue Shield of Alabama, denoting quality care; and separate accreditations by the Academy of Sleep Medicine, the Food and Drug Administration (for breast-care services), the American College of Radiology, and the Commission on Cancer of the American College of Surgeons, among others.
RMC has been Joint Commission accredited for 51 years, Williamson said.
Areas needing improvement, according to the Joint Commission’s report include: labeling and storage of medication, completion of medical records, maintenance of fire-safety equipment and building features, and planning and documentation regarding anesthesia.
In the surveys, in addition to the requirements for improvement, RMC scored above the performance of most accredited organizations in heart-failure care.
In the end, Williamson said, having the “gold standard of surveys,” represented by the Joint Commission, even if there are areas needing improvement, “is an opportunity to improve the quality of care we offer.”
Once the appeals process is completed, “we expect to be back in full compliance. We take it very seriously,” she said.
About Mary Jo Shafer Mary Jo Shafer is assistant metro editor and business editor for The Star.
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