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Quality

Regulatory Readiness

Regulatory Readiness is about the Next Patient Not the Next Survey

Hospital Accreditations

 

Department of Health

Hospital
Last Survey:  3/23/10-3/29/10
Results:  Outstanding survey.  There were only three citations received:

  1. Focus on the drying time of the alcohol based surgical skin prep, making sure prep was fully dried prior to the start of the case
  2. Monitoring of temperature and humidity in the nursery
  3. Monitoring of temperature and humidity in the bronchoscopy procedure room

Behavioral Health
Last Survey:  January 25, 2012
Results:  Outstanding survey, no citations.


Joint Commission


Hospital
Last Survey:  February 1-4, 2011
Results:  Outstanding survey.  There were only two direct and six indirect impact requirements
Received:
 

  1. Two direct requirements pertained to one exit sign that was not lit and sidewalk needed repaired.
  2. The six indirect impact requirements included:  a) Space issue in the lab, b) Documentation concern in Echo department, c) Signing of orders prior to surgery, Medical staff review of medical imaging job descriptions, e) Proctoring of new physicians, and f) Expansion of the ongoing professional practice review of the medical staff.

Senior Care Pharmacy
Last Survey:  February 1-4, 2012
Results:  Outstanding survey, no deficiencies

Behavioral Health
Last Survey:  February 1-4, 2012
Results:  Outstanding survey, only one deficiency regarding the care planning process.

Laboratory
Last Survey:  September 27-29, 2011
Results:  Outstanding survey, there were no direct impact requirements received.

  1. There were only seven indirect impact requirements received:  a)  Space issues in the lab, b) Expansion of staff competencies, c) Proficiency testing participation enhancement, d) Instrument-based testing prior to instrument use, e) Review of transfusion-related adverse events, f) Identification of specimens, and g) Waived testing recordkeeping.