Who remembers that The Joint Commission was here from May 21st – May 23rd? Several months have passed since our full hospital accreditation survey, and a great deal of time, effort, and even some research has gone into the work to correct the recommendations made by our surveyors. All of that effort has paid off, because on Friday, August 16 we received notice that all of corrective actions were accepted by The Joint Commission, and we have again been granted full hospital accreditation!
As you may have heard, our beautiful fireplace in Med/Surg/Peds was potentially in jeopardy following our survey, but thanks to Plant Services’ we not only can we keep the fireplace, but we can turn it back on as well! Plant Services worked to ensure that additional safety mechanisms were in place, which allows us to continue to operate the fireplace. Thank you to everyone for supporting me through all of our surveys and inspections this year, and for your quick responses when you received notice that we had surveyors in-house.
Three of the recommendations require four months of Measures of Success data collection, which is due to The Joint Commission on December 14th. A recent check of this compliance data indicates that there should be no problem meeting the goals that we established.