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Hospital passes surprise survey

Mary Washington Hospital has been accredited after its first unannounced Joint Commission inspection

Date published: 10/25/2007

BY JIM HALL

When hospital employees arrived for work on a Monday morning in mid-June, they heard an intercom announcement that they had long expected.

"Mary Washington Hospital is happy to welcome our Joint Commission surveyors," the operator said.

The announcement was an alert to everyone that D-Day had arrived. Inspectors were in the building.

Every three years the Fredericksburg hospital submits to an inspection by a team from the Chicago-based Joint Commission.

The organization has been inspecting the nation's hospital's for more than 50 years. Its accreditation is prized, in part because government and private insurance plans insist on it.

In the past, Joint Commission inspections were scheduled ahead of time, and hospitals were able to prepare for them.

It was as if "company's coming and you're making yourself look good," said Eileen L. Dohmann, vice president for nursing.

But last year the commission switched to unannounced inspections in hopes of seeing hospital operations as they really are.

Mary Washington officials knew they were due for an inspection, but because of this change, didn't know until that morning in June when it would occur.

"You didn't get to cram for the test," said Kevin Van Renan, senior vice president.

A seven-person team consisting of doctors, nurses and former administrators spent a week at the hospital, going throughout the building.

Dohmann said their message to the executives who followed them was: "We'll tell you what we want to see." The team talked to staff and patients, inspected charts and examined written policies. They also used a "tracer" method of tracking patients throughout their stays.

Dohmann said one of the surveyors found a patient in the emergency department who had come to the hospital with chest pain. The surveyor tracked the man from the ER to his room in the hospital, to treatment in the cardiac catheterization lab, and finally to discharge.

At each stop, the surveyor quizzed the staff about hospital policies, about how the man was treated, and about how they transferred information about him to others in the chain.

"I think it's a much better methodology than what they used in the past," Van Renan said.

At the end of the week, the surveyors met with executives and praised the hospital, calling Mary Washington "very, very, very good," Van Renan said.

While they were in Fredericksburg this summer, Joint Commission inspectors generally praised Mary Washington Hospital. But they did find things about the hospital that could be better. These included: Record keeping in the patient charts. The fire alarm system. Under the old policy, someone investigated a fire alarm and then notified the fire department if necessary. The surveyors asked that the fire department be notified immediately by an electronic signal when an alarm is sounded. The system was changed. Inspection of unused anesthesia. Unused anesthesia is returned to the pharmacy after surgery. The pharmacy staff measures the volume of the returned material to guard against theft. Surveyors asked that the staff also do a random analysis of the material. Enforcement of the no-smoking policy. Surveyors found what appeared to be a smoking area in one of the first-floor stairwells. They also found numerous cigarette butts at the front entrance.

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Date published: 10/25/2007