Hospital makes "A" during Joint Commission and CMS accreditation review surveys

Highlands-Cashiers Hospital has once again not only met the standards of the nation’s leading organization that accredits hospitals and other healthcare providers, it received verbal high marks from those who conducted the review.

The Joint Commission recently awarded full, three-year accreditation to the hospital, its nursing center, and Highlands-Cashiers Hospice, based on a comprehensive on-site survey conducted in June. Joint Commission accreditation is “the Gold Seal” for quality and safety within the health care industry.

What’s more, the hospital also fared well during a follow-up validation survey by the Center for Medicare and Medicaid Services (CMS). By federal law, CMS is required to perform its own survey of at least 5 percent of those hospitals that elect to undergo Joint Commission review to recheck that private organization’s findings. Hospitals that wish to accept Medicare and Medicaid reimbursement must be periodically reviewed by either The Joint Commission or CMS. The CMS survey was conducted at the end of July.

“We made an ‘A’ if not and ‘A’-plus,” said Griffin Bell, Jr., who co-chairs the hospital’s Patient Care Committee. “What the primary inspector from Joint Commission essentially told us was that our hospital passed with flying colors. He was very complimentary of the hospital and the care it provides.”

The Patient Care Committee (formerly the Performance Improvement Committee) is made up of board members like Bell and co-chair Dr. Jim Rothermel, hospital staff, active physicians, and members of administration. It monitors how the hospital performs against a number of key healthcare industry benchmarks to ensure that high-quality patient care is being provided.

“We are closely in touch with the entire process that monitors the care the hospital provides. The committee is a place for patients and family members to go if they have concerns regarding care or patient safety,” explained Dr. Rothermel, a retired OB-GYN physician and former associate clinical professor of medicine at the University of South Florida School of Medicine.

Both of the visits by the two survey teams were unannounced, and while both groups of surveyors did find room for improvement, Vice President of Operations Frank Leslie said all of the issues cited were minor – most involving the need for better documentation.

“They didn’t find any issues related to patient care,” said Leslie. “The Joint Commission sets very high standards and we met those standards.”

Leslie said the hospital knew it would undergo a Joint Commission visit sometime this spring or summer, but that the hospital has not been simply focused on being ready for inspectors. “Our goal all along has been to be ready for our next patient, not the Joint Commission,” he said. “We need to be providing the highest level of care possible to every patient that comes through our doors. If we are ready to do that, we will be ready for Joint Commission or whomever decides to come inspect us.”

The hospital has already begun implementing those minor recommendations made by the Joint Commission, Leslie said. The CMS survey also produced several recommendations, most involving documentation as well, but none were serious enough to require a formal response. Even so, Leslie said the hospital will respond.

Leslie and Bell both pointed out that surveyors had commented on the fact that it was rare for a small, Critical Access designated hospital to have so few deficiencies. “The surgeon who was part of the inspection team, called our hospital extraordinary. That about says it all,” Bell concluded.