Published in The Post-Star (A1)
3/27/06
When accreditation surveyors from the Joint Commission visited Glens Falls Hospital last July, they didn't like everything they saw.
The Joint Commission, an association that accredits about 15,000 health care organizations nationwide, issued "conditional accreditation" to Glens Falls Hospital for the first time in the hospital's history, and left behind a list of 13 "requirements for improvement."
Those requirements included things like keeping up with fire codes, documenting regular testing of crucial medical equipment like sterilizers and ventilators, storing medications properly, assessing pain in all patients, and developing a hospital-wide system to quickly identify and address any problems in the environment of care.
This spring, Joint Commission surveyors will return to see if those requirements have been met.
"Conditional accreditation means the hospital is out of compliance with a number of standards, and must demonstrate compliance with those standards in order to maintain their accreditation," said Char Hill, a spokesperson for the Joint Commission. "The hospital is likely working very hard to come into full compliance."
That's true, said Glens Falls Hospital CEO David Kruczlnicki.
"We're anxious for them to return," he said. "As soon as they verify that the things they have suggested to us have been addressed, we'll swap to full accreditation."
One part of the survey compared the hospital's voluntarily reported data with state and national statistics in three critical areas of patient care. Glens Falls Hospital scored above average for heart failure care, average for heart attack care, and below average for pneumonia care.
In recent months, the hospital has worked to improve the speed and accuracy of blood culture collection in pneumonia patients, the key area in which its score suffered. Blood cultures can help determine the most effective antibiotic for treatment.
Since the survey, blood culture collection rates in pneumonia patients at Glens Falls Hospital have gone up from 64 percent to 72 percent of pneumonia patients, according to Carol Shippey, vice president for patient services. The state and national average is 82 percent.
Most of the problems that surveyors found were not with the substance of the hospital's procedures, but with consistent documentation of those procedures, Kruczlnicki noted.
"We're pleased that the central part of their recommendations for us had to do with non-direct patient care," said Kruczlnicki. "And frankly, to some degree, I think we may have been a bit distracted with the construction of the new Northwest Tower when the surveyors were here. We should have had all this documentation then, but we have it now."
Since the Joint Commission's last visit, the hospital has introduced a new computerized maintenance system to make record keeping more timely and consistent.
Kruczlnicki also pointed out that the Joint Commission has recently been tinkering with its accreditation method. "Conditional accreditation" was not something that existed the last time Glens Falls Hospital was reviewed. The hospital has been accredited by the Joint Commission since 1954, and surveys are typically conducted every three years.
"I don't want to sound defensive about the jargon, but it's the first time they've had that terminology, and from what I understand, it's not unusual for a hospital to have conditional accreditation," said Kruczlnicki. "The whole idea is that it's a learning experience."
According to the Joint Commission's Web site, Saratoga Hospital and Albany Medical Center both received full accreditation in their most recent surveys. But that doesn't mean they were perfect, either.
In the area of "heart failure care," the commission gave Saratoga Hospital a "below average" score in September 2004. Since then, hospital staff have sharpened their focus on quality improvement initiatives in this area, such as reducing the rate of bloodstream infections when central lines are inserted.
"When we identify an area that needs improvement, we review that, develop a strategy and put an action plan in place to get ourselves to the mean or above the mean," said Susan Hodgson, quality director for Saratoga Hospital.
The hospital also has something called a "Joint Commission readiness team," she said, that focuses on keeping up with each chapter of the most current accreditation standards. Although Joint Commission accreditation is voluntary, it's standard procedure for most major hospitals.
"These days, aligning yourself with their standards is really the right thing to do. You don't just do it for the sake of accreditation -- it really does substantiate quality and excellence in patient care," Hodgson said.
Kruczlnicki said he agrees, and welcomes the commission's visits.
"We chose to participate because every survey is a learning process. The surveyors that visit us interact with virtually every hospital in the country, and through doing that, they identify the best practices for hospitals," he said. "We can learn from them what the best of institutions are doing to provide the best care, so we can constantly improve the quality of our care."
ONLINE RESOURCES:
The following Web sites offer comparative data on hospital quality indicators, searchable by ZIP code:
Joint Commission: http://www.jcaho.org/qualitycheck
Dept. of Health and Human Services: http://www.hospitalcompare.hhs.gov
Agency for Healthcare Research and Quality: http://ahrq.gov/qual/hosptools.htm
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