Joint Commission report sparks response, reflection

A report issued by Joint Commission surveyors after a recent visit will trigger more than immediate corrective action, says Aaron Kocsis, R.N., regulatory coordinator with WVU Medicine’ s Center for Quality Outcomes.

It should also provoke some big-picture thinking.

“I would encourage everybody to read the report,” Kocsis said. “It’s a true learning opportunity. Everybody can benefit from this.”

Kocsis said the report yielded a similar number of issues to the surveyors’ last visit, which was in 2012, but the nature of some of the problems, which are linked to Centers for Medicare and Medicaid Services (CMS) standards will need to be corrected within 30 days.

Organizations typically have 45-60 days to implement corrective action on non-CMS issues.

“The observations from the preliminary report didn’t change, they were just categorized differently,” Kocsis said.

A site visit to check the corrective action on the CMS-related issues will occur sometime between Sept. 20 and Oct. 5. Another check on the progress of all other issues will likely occur in January, 2016, Kocsis said.

Accreditation will depend on compliance with the Joint Commission’s final recommendations.

Five clinical surveyors were on site the week of Aug. 17 and issued a preliminary report on the last day of their four-day tour. The focus each survey is broad, ranging from among 18 areas of care, with questions that may pertain to any one of the organization’s 1,700 standards of care. Visits are scheduled 18-36 months after surveyors were last on site and occur unannounced.

Some problems noted on the report were corrected on the spot; others may take training or a review and tweaking of a process.

The ultimate goal, says Kocsis, is to improve patient safety.

“You have to have the right attitude when you approach this, a healthy attitude,” Kocsis said. “The report lists some items that need to be corrected but we heard so many comments by the survey team that were complimentary, saying that we had best practices in place.”

After the survey team filed the preliminary report, the Joint Commission’s main office reviewed the findings and issued a final report.

After receiving the preliminary report, Kocsis met with 45 team leaders throughout WVU Medicine to evaluate and correct problems. Team leaders are a mixture of staff and staff in leadership positions. But Kocsis notes that all staff members are crucial to the process.

“Everybody plays a role in this,” he said. “Staff who may not be formally assigned as a team leader are being counted on to take corrective action. Or a team leader may seek them out to make sure their ideas will work and flow correctly and not create more problems down the road.”

Teamwork has been an overall theme throughout the preparation process and the visit.

“This office wants to thank everybody for their effort,” Kocsis said. “Everybody participates, everybody puts forth effort. We appreciate everybody’s help coordinating this. This is a large scale event.”