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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 and Services
  • Surveillance, Prevention, and Control of Infection
  • Leadership
  • Improving Organization Performance
  • Management of the Environment of Care
  • Management of Human Resources
  • Management of Information
  • Medical Staff
  • Nursing

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
Web Site


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