The Joint Commission (TJC) conducted an unannounced survey at the UW Medical Center (UWMC) Sept. 17 - 21. TJC evaluates and accredits nearly 15,000 health-care organizations and programs in the United States. TJC recently began using unannounced surveys as part of its accreditation process, and this was UWMC’s first survey under this process.
TJC has been accrediting facilities for 50 years. Achieving accreditation means a hospital meets high national standards for patient safety and quality of care. UWMC must go through the accreditation process once every three years. Not only is our funding for Medicare, Medicaid and Graduate Medical Education tied to this accreditation, but the survey status is also made available to the public.
The Joint Commission surveyors who visited UWMC were impressed with our facility, physicians and staff and the level of board engagement. At the summation conference held Friday, Sept. 21, to share accreditation results, surveyors personally thanked staff for hospitality, openness and assistance during the survey week. “It was a pleasure to see such an outstanding organization in action,” the physician surveyor said.
Two Requirements for Improvement (RFIs) were identified. The first RFI relates to the medication management standard: The Joint Commission surveyors noted that they observed four expired medications.
For the second RFI UWMC will modify a current patient safety protocol to better match the Universal Protocol (for preventing wrong-site, wrong-procedure, wrong-person surgery) as defined by The Joint Commission. UWMC has had for a number of years, a time-out process in place to address the Universal Protocol. The time-out occurs immediately prior to invasive procedures and involves the entire medical team. During the time-out, active communication occurs and specific items must be discussed including patient identity, correct side and site of procedure and agreement on the procedure to be done.
We have already begun to implement necessary changes to respond to the RFIs and to enhance our processes to improve in these areas. Our staff and faculty are fully committed and will embrace what is required to provide the highest quality patient care at UWMC.
See detailed information on the RFIs in the related executive summary of The Joint Commission Accreditation survey findings
The Joint Commission accreditation process is truly a learning experience that we always welcome.
I look forward to working with staff and UWMC leadership to continue to improve upon our Patient Safety, Quality, Access and Satisfaction, Outcomes goals, and welcome any questions you might have regarding UWMC and The Joint Commission accreditation process.
Sincerely,
Stephen P. Zieniewicz, Executive Director
The University of Washington Medical Center (UWMC) is a 450-bed academic medical center that provides highly-specialized care including, general medicine and surgery, transplant services, neurosciences, cardiology, orthopaedics and rehabilitation. In addition the UWMC's oncology inpatient and outpatient services are affiliated with the Seattle Cancer Care Alliance. UW Medical Center serves Washington, Wyoming, Alaska, Montana and Idaho, a region referred to as WWAMI.
The UWMC was the first in the nation to be designated a Magnet Hospital for nursing excellence in 1994 and the first to receive the honor three times. U.S. News & World Report has consistently ranked UWMC among the top hospitals in the country. UWMC is part of UW Medicine, which includes Harborview Medical Center (the only Level I trauma and burn center in a four-state area), the UW School of Medicine and the UW Neighborhood Clinics.