Joint Commission Completes Accreditation Survey

The Joint Commission completed a triennial, unannounced accreditation survey at Knapp Medical Center in Weslaco the week of February 9-13, 2009.

Formed in 1951, the Joint Commission is dedicated to improving the quality of the nation's health care through voluntary accreditation. In other words, Knapp requests the accreditation survey.

“Surveyors made the unannounced inspection and were pleased with the best practices they observed at Knapp pertaining to patient safety,” CEO James A. Summersett III said.

“There were many areas where Knapp excelled, and there were some practices identified that need improvement,” he said. “But the surveyors all commented on the courtesy, friendliness and teamwork of all Knapp staff members and the cleanliness of the hospital.”

The five-day, on-site survey used “tracers,” which focus on individual patients who are selected and followed by a surveyor through the hospital system in the sequence they received care. If a surveyor notes problem trends, a direct impact or indirect impact recommendation for improvement is issued.

A requirement has a “direct impact” if noncompliance is likely to create an immediate risk to patient safety or quality of care. An example is proper site marking for surgical procedures. Indirect impact issues include procedures, training and other areas that have less immediacy of risk but are requirements that must be met.

One tracer involved a patient who came to the Emergency Department and was admitted to the Intensive Care Unit. “They followed this patient through the entire delivery-of-care process, which involved numerous departments,” said Chief Nursing Officer Madonna Coughenour R.N. Tracers were conducted through every patient care area and clinical service and most non-clinical services.

Surveyors report their findings to the hospital's CEO and to the Joint Commission. The hospital has 45 days to submit Evidence of Standards (ESC) for Direct Impact issues and 60 days to comply with Indirect Impact requirements. Once the ESC has been reviewed and accepted, the accreditation decision is made.

During the exit interview, surveyors mentioned potential direct and indirect impact standard findings for both Knapp and Knapp Hospice; however, the official findings will come from The Joint Commission.

There are about 2,100 standards Joint Commission surveyors consider. The report from the surveyors' February visit will go to the commission's headquarters outside Chicago, and Knapp will be graded on a curve with like-size hospitals.

“We are a fully accredited hospital and we expect to remain fully accredited,” Summersett said.

A full survey of Knapp was last conducted by the Joint Commission in December 2005. A one day, on-site survey also was conducted in January 2008. A follow-up of the January survey was completed in April 2008, and full accreditation was maintained. Unannounced one-day surveys can occur at any time and the full, five-day survey Knapp undergoes can occur from 18 to 36 months after the last full survey.

“I'm extremely proud of our team. Not only for their hard work during the visit but for providing always and consistently excellent care for every patient, every time,” Summersett said.

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