KGH earns excellent marks
in re-accreditation survey
February 15, 2005
Ketchikan, Alaska - The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) surveyed Ketchikan General Hospital
(KGH) for re-accreditation on January 19-21, 2005. The survey
encompassed all KGH programs including the hospital, home health
care, long-term care and clinics.
The Joint Commission is an
independent, not-for-profit organization that sets standards
by which health care quality is measured in the USA and throughout
the world. To earn and maintain accreditation, organizations
must have an extensive on-site review by a team of JCAHO surveyors
at least once every three years. The purpose of the review is
to evaluate the organization's performance in areas that affect
patient care. Accreditation may then be awarded based on how
well the organization meets Joint Commission standards. JCAHO
offers a searchable website so consumers may see for themselves
how a particular health care facility has scored.
Approximately 250 standards
are evaluated, each standard comprised of numerous "elements
of performance". They fall under these general headings:
- Ethics, Right and Responsibilities
- Medication Management
- Provision of Care, Treatment
- Surveillance, Prevention,
and Control of Infection
- Improving Organization Performance
- Management of the Environment
- Management of Human Resources
- Management of Information
- Medical Staff
The KGH survey resulted in
only minor requirements for improvement, primarily related to
documentation. Deficiencies were limited to these:
- KGH Policy requires that pain
be assessed on a one-to-ten scale with each Home Health visit.
There were four visits noted where this assessment may have
been done but was not documented in the patient's record.
- KGH Policy requires that when
an order is given by phone, the nurse taking the order must read
it back to the physician to double-check that it was heard accurately.
Then "RB" (for "read back") is noted in
the patient's record. There were three occurrences where the
RB notation was not made in the medical record.
- Abbreviations and symbols
are standardized throughout the hospital, and KGH has a list
of abbreviations that are not allowed because of the possibility
of confusion with similar abbreviations. Surveyors found four
orders where unacceptable abbreviations were used.
- In addition, the surveyor
found four oxygen tanks unsecured and a fire door that did not
latch properly. Both problems were corrected immediately.
The surveyors' comments indicated
they were very impressed with the KGH facility and staff, stating
the "nursing staff are very knowledgeable" and "we
run a very tight ship". They also commented on how technologically
advanced we were given our remote location and size, making special
note of KGH's computerized medical record.
The hospital has three months
to develop and implement an action plan addressing the deficiencies
found. Once the plan is accepted, the hospital will measure compliance
for four months. After that point, a final accreditation decision
will be made.
Source of News:
Ketchikan General Hospital
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