RMC working hard to renew Joint Commission accreditation
by Patrick McCreless
pmccreless@annistonstar.com
May 30, 2013 | 5682 views |  0 comments | 49 49 recommendations | email to a friend | print
Regional Medical Center in downtown Anniston is shown in this file photo. (Photo by Trent Penny/The Anniston Star)
Regional Medical Center in downtown Anniston is shown in this file photo. (Photo by Trent Penny/The Anniston Star)
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Nicole Meads has spent many hours preparing Regional Medical Center for surveyors who will decide if the hospital meets nationally recognized medical standards.

Failure to meet those standards could mean the loss of Medicare reimbursements and private insurance money.

Meads can hardly wait for the surveyors to arrive.

"I wish they would come now," Meads said. "We're ready."

Meads, a registered nurse and quality improvement manager, is on a team of RMC employees which has helped the hospital prepare to renew its three-year accreditation with the Joint Commission, a national nonprofit body that evaluates health care organizations on patient safety and quality of care improvement. The unannounced four-day survey, which could happen this week or a month from now, will not only determine whether RMC can continue to operate, but also show whether the hospital has improved care and patient safety.

Federal law requires hospitals be accredited and meet federal standards to receive operating licenses. According to the Joint Commission website, the body accredits approximately 82 percent of the country's hospitals.

"It's tough and thorough and a good thing for a hospital to go through," said Rosemary Blackmon, vice president of the Alabama Hospital Association.

Nisha Madhavan, a registered nurse and chief nursing officer at RMC, said the hospital's staff works tirelessly to find ways to improve standards and care.

"It's an ongoing process of continuous quality improvement ... it's not just for the Joint Commission," Madhavan said.

But without Joint Commission accreditation, RMC would have a difficult time funding its services.

"Unless you have accreditation, insurance won't pay you," said Mark Cova, director of plant operations at RMC. "And Medicare will not pay."

Medicare is a federal program that provides health care funding mainly for the elderly and people with disabilities.

"If a hospital wants to take Medicare patients, they have to meet the Joint Commission criteria," Blackmon said.

RMC risked losing its accreditation in 2007 after failing parts of the Joint Commission's survey. Areas that failed the survey included labeling and storage of medication, completion of medical records, maintenance of fire safety equipment and documentation regarding anesthesia.

However, after several improvements at the hospital, RMC bounced back and received high marks from the Joint Commission's following survey in 2010 — meeting every one of the organization's patient safety goals.

"One of our main focuses is improving patient safety," Madhavan said.

During its survey, the Joint Commission will check whether RMC is meeting national patient safety goals such as infection prevention, staff communication and ensuring patients are receiving the correct medicine.

"They will observe a nurse giving medicine to a patient, look at our policy and procedure on that, then match our practice to our policy and procedure," Madhavan said.

The Joint Commission will also review RMC's safety codes, emergency power systems, job responsibilities, medical storage and other aspects of the hospital.

"And the Joint Commission expects us to teach all this stuff to the entire hospital staff," said Cova, who is also part of the core Joint Commission team at RMC. "They'll meet with us to see if we know everything, but they'll also want to talk to others like a custodian and maybe ask him about the hospital's fire procedure."

Adding to the complexity of the standards is that the Joint Commission regularly updates them, forcing hospitals to further improve themselves. The Affordable Care Act, the federal health care reform law passed in 2010, has also triggered improvements in the Joint Commission's standards, such as when and how a catheter should be used on a patient to decrease the chance of urinary tract infection, said Kandi Williams, infection preventionist at RMC.

Williams said many of the hospital's nursing staff recently underwent updated training in the use of catheters, devices typically used for the drainage or administering of fluids to a patient. Williams said that since the new training was implemented in January, the urinary tract infection rate has dropped from 2.43 percent to 0.3 percent at the hospital.

"It's a national patient safety goal to lower the rate, required by the Joint Commission," Williams said.

Williams said several improved eye washing stations were added around the hospital to improve safety. Also, under updated Joint Commission standards, RMC this year had to document how many employees received flu vaccine and the reasons why employees didn't take the shot. Williams said the goal of the requirement is to show improvement in employee vaccination and eventually have 90 percent of hospital workers vaccinated against the flu by 2020.

Cova agreed with Madhavan that the hospital is constantly looking for ways to improve, regardless of the Joint Commission. He said the hospital is upgrading its sterilization room for surgery tools to make it more efficient and reduce the chances of patient infections — a change that is not required by the Joint Commission.

"This doesn't create revenue like adding operating rooms," Cova said. "We just saw some improvement that needed to be done ... it's something for safety."

Staff writer Patrick McCreless: 256-235-3561. On Twitter @PMcCreless_Star.
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