Q: What is survey process like for organizations pursing accreditation for disease programs?
Vicki Hoffman: It was similar to pursing regular Joint Commission certification. We looked at the application and found out what the requirements were. We had to choose four performance measures for reporting to The Joint Commission. When identifying performance measures, it had to be a team effort. It couldn’t be one person pulling data out of the computer and saying that represented our program. Everyone had to be working together. We’ve engaged the staff in choosing the performance measures because the performance measures had to be meaningful to the program and to the staff involved. We know that this is an important way in which staff are empowered which lead to them feeling like a stake holder in the program.
When The Joint Commission came onsite to do the survey, it was like a regular review. Basically, they were looking to validate that what we said about the program was true and that we met Joint Commission standards. It’s an all-day process for each disease program, one day for the lumbar spine fusion and another for the hip and knee.
Q: Why did you choose to go through the disease program accreditation?
VH: We wanted to demonstrate to the public that we had a high quality program. We also were looking to distinguish ourselves amongst our competitors. The staff is also proud of this accomplishment and feels vested in the program having gone through the survey. Likewise, it’s a great recruitment tool. We believe that this has elevated the entire organization to a higher level of care.
Q: What was the most challenging aspect of the accreditation process?
VH: During the first time we pursued disease specific certification, the biggest challenge was getting everyone to buy into the necessity for the additional “work.” We were electively inflicting this upon ourselves. The award in the end was that we were part of the experience and very proud of the accomplishment. After the first one, the second and third were more comfortable and the staff better understood and believed in the importance of the certification.
Q: How did the hospital create enthusiasm and compliance with the accreditation standards the first time?
VH: We tried to encourage our staff. We looked at other hospitals around the country and gleaned ideas from them. We talked a lot about the unique qualities of our program. We told our staff, “We want to really develop this into a program that exceeds and excels in every way and we want you to be part of it.” We don’t want to be just another hospital that does joint replacement surgery; we want to continue to develop a program that provides patients with the best possible experience. The certification has been a morale booster for the staff.
Q: What was the biggest change you made as a result of the accreditation?
VH: While we were doing the mock surveys we would identify deficits. Sometimes, patient records were not dated or timed, though they were all supposed to have that information. However, the forms did not prompt for that information. We fixed that. We continue to do mock surveys and our own tracers. Developing and maintaining the discipline of mock surveys not only helps with reviewing compliance issues, but also allows us to review time and again the operations of the program so we can work proactively to be in a constant state of program refinement.
Q: What advice would you give to a hospital seeking accreditation?
VH: It’s really important they have a complete collaboration between every discipline. It’s an absolute necessity for the surveyors and patients to see and feel what you represent yourselves to be true. There has to be everyone working together. We had significant surgeon participation; they were present the day of the survey and participated in all the preparation. We tried to minimize the drain on the surgeons’ time, but they stepped up which made everyone else feel all the more engaged when the surgeons took such a strong lead. For the lumbar spine fusion certification, the surveyor was impressed by the neurosurgeons and spine surgeons working together on a process. It was a fantastic experience.
Learn more about The Stamford Hospital.
Read other coverage on orthopedic accreditation:
– Carolinas Medical Center-Mercy Receives Total Hip and Knee Replacement Certification
– AAAHC Institute Releases Three Quality Studies For Common Outpatient Procedures
