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UNHS preparing for Joint Commission survey in 2016 - Medically Speaking, Volume Three, Number Four, 10/8/15

With the next Joint Commission survey expected sometime between January and April of 2016, administrators and staff at Utah Navajo Health System, Inc. have been busy preparing for an intense round of inspections.

UNHS has earned Joint Commission Accreditation since 2003 and prides itself of upholding the highest standards for healthcare professionalism, safety and compliance with Joint Commission requirements across the board. The Joint Commission is an independent, not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. The Joint Commission's Mission is to "continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."

Only about 13% of clinics across the United States, and only seven in the State of Utah, have been accredited by the Joint Commission, according to Donna Jensen. She explained that of those seven in Utah, the four UNHS Community Health Centers in Blanding, Montezuma Creek, Monument Valley and Navajo Mountain count as one. Surveyors will visit each UNHS clinic and each must meet the same rigid accreditation standards.

Jensen and Sylvia Lopez, who directs the UNHS Patient Care Medical Home program, have been working continually for the past three years to ensure UNHS is ready for the next Joint Commission visit. All seventeen accreditation requirements, called Elements of Care, have to be met, Lopez explained. And each Element of Care has it's own set of standards that must be met.

"They have a book that is the Bible and we review standards constantly. We have a team that reviews quarterly. We go around to every clinic and every dental clinic with a huge checklist and we ask them questions," Lopez explained. "We check for safety, infection, if a place is clean, we check for updates, for expirations, compliance, education and we write it up. We have seminars with all clinical, nursing and medical assistants. We just had a seminar with all providers in medical, dental and behavioral health just on reviewing standards. We also had a business staff meeting with different departments to get everyone on same page."

Jensen said when surveyors arrive they just show up one day at the front desk.

"And they have surveyors who look at compliancy, and all the standards, not only patient care but governance too. Performance improvement. Everything from health records to patients' rights and responsibilities. They set the guidelines and we just try to meet each and every guideline," Jensen noted. "They want us to live the highest standards, which is very good because honestly, when you have a lot of people who think they all know a standard, it might be very different, but when you have THE standard then everybody knows, this is the standard. So it's safer for the patient and that's the whole issue – patient safety."

UNHS officials attend Joint Commission conferences in April and November with healthcare professionals from around the world to discuss standards. Then they return home and discuss those standards with their staffs. Over the past three years, Jensen and Lopez have documented all their efforts to ensure uniform compliance with all Joint Commission standards and have several plastic bins full of that documentation.

"There's a lot of data and we can look and see how compliant are we. People are really open to it now. Before we used to say, 'this is a joint commission standard' and people would resist and they'd forget about it in two weeks. But now it's like, 'okay this is the standard' and they don't forget about it," Lopez said.

According to Jensen, UNHS providers and staff now work better together as an organization because they do know the standards.

UNHS CEO Michael Jensen said the efforts by Donna and Sylvia have been very successful and he feels the organization will be ready for the next visit by Joint Commission. As another preparatory measure, UNHS arranged for two Joint Commission surveyors to fly in for a mock survey at three of the UNHS clinics in mid-September. He said the pair spent two days looking at the same things the surveyors will examine when they come for real in 2016. Providers and staff were not told of the mock visit until the night before to make it a surprise visit.

"Overall, I think we did real well. They complimented the number of programs and services we provide, the cleanliness of our clinics, our professionalism, and the knowledge of our staff," he said. "There are areas we need to tighten down and clean up, but things we were cited for three years ago, we weren't cited for this time around. We will be ready when they come next time."

Jensen said the next survey could also include a survey by the Health Resources Service Administration

(HRSA), an organization that focuses mainly on the financial and clinical operations of an organization. Donna said UNHS hopes to be part of this pilot program to see how well various organizations do in the survey. It could become standard across the nation.

"These ladies have done a really great job getting us ready for Joint Commission," Michael said of the work Donna and Sylvia have done. "We don't want to just pass this survey, we want to knock it out of the park. I think they should be proud. This is a different way from what we've done in the past and I think it's going to really help us be ready."

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