SYLACAUGA — Coosa Valley Medical Center has received an outstanding review from a national health care accreditation organization from a survey of the hospital, home care and lab.The Joint Commission on Accreditation of Healthcare Organizations completed a four day survey at the hospital in mid-July. The JCAHO does these surveys every three years, said Glenn Sisk, hospital CEO.
“The JCAHO serves hospitals throughout the country to review processes and the level of quality delivered in the patient care setting. They expect facilities to adhere to over 1,100 elements of performance that are evaluated during their triennial surveys. The staff of Coosa Valley Medical Center has once again demonstrated that our local hospital is performing among the highest in the nation,” he said.
Some changes were made in the survey starting in 2004. Health care facilities no longer know when the visit will take place for the survey by JCAHO, only the year. Coosa Valley Medical Center officials knew the survey would occur in 2006, Sisk said.
The Joint Commission evaluates and accredits nearly 15,000 health care organizations and programs in the United States. An independent, not-for-profit organization, the commission is the nation’s predominant standards-setting and accrediting body in health care.
JCAHO is governed by a 29-member board of commissioners that includes nurses, physicians, consumers, medical directors, administrators, providers, employers, a labor representative, health plan leaders, quality experts, ethicists, a health insurance administrator and educators. It employs more than 1,000 people in its surveyor force.
Three years ago, the hospital received one of the highest scores among Southeast hospitals for its accreditation survey. The 98 score on the accreditation survey placed the hospital in the top 7 percent in the country, Sisk said.
The commission eliminated the score aspect of the survey in 2004, said Carla Taylor, director of continuum management for the hospital.
Taylor, Vanessa Green, vice president of senior support and marketing services, and Amy Price, vice president of patient care services, worked with the Joint Commission on the survey when they came to the hospital July 18-21.
The survey philosophy, Taylor said, was changed so health care facilities would continually try to improve the quality of service they provide.
Instead of scores, facilities are given their results based on RFIs, Recommendation for Improvements.
If a facility receives 12 or more RFIs, it is at risk. Most facilities across the nation average 8 to 9 RFIs, Taylor said.
CVMC has only two RFIs, Sisk said. No hospitals CVMC networks with in a 45 to 50 mile radius have received this type RFI, Sisk said. This includes Russell Medical Center, East Alabama, Trinity, UAB, St. Vincent’s, or Princeton.
“The results are a credit to the collaborative efforts of our medical staff and team members and the countless hours of preparation that go into preparing for a survey. The process has now changed such that a facility must be in continuous readiness mode. The surveys are no longer scheduled requiring our team to always be prepared. We believe this change has been beneficial to patients as we strive everyday to deliver the highest quality care possible,” Sisk said.
The hospital CEO said what is encouraging to him is this survey comes on the heels of results three years ago that placed CVMC in the top 7 percent of hospitals throughout the country.
“We will not know where these results from this survey just completed will place us until the year concludes, but I am confident that we will exceed the incredible performance of the last survey cycle,” he said.
Health care officials from Virginia and Florida did the survey of CVMC, Price said. These officials have no connection to the hospital.
Patients surveyed were randomly selected by the JCAHO team based on the top diagnosis, Price explained.
The commission’s on-site survey process focuses on the care provided by the hospital and involves the hospital’s staff in the survey.
The tracer methodology guides the on-site evaluation by following or “tracing” a number of patients through the hospital’s entire care process. The hospital is required to continuously remain in compliance with all standards. Accreditation or certification is not automatically renewed.
Standards of the commission are heavily focused on patient safety, particularly in the areas of medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staffing and staff competence, fire safety, medical equipment, emergency management and security.
Green said the hospital will celebrate the results of the survey with its employees Aug. 16 from 11 a.m. to 1 p.m. on the lawn of the hospital.
“It takes all of us to make this work and to have continued success,” she said.
The hospital has about 580 employees.
Sisk said members of the community and this region can remain confident the services delivered at CVMC are done so at a high level.
“It is our hope the personal touch provided by our staff also exceeds the expectations of those we serve. It is with great anticipation we await the opening of our West Wing project in the spring which will provide yet another opportunity to expand our services,” he said.
