West Valley Medical Center - July 19, 2019

2 min Read Time

Renee DeHaas
Director of Quality and Patient Safety

Joint Commission survey results

As most of you are aware, we have been preparing for the arrival of The Joint Commission for our Triennial accreditation survey due in October of this year. We were convinced they would come early, and on the morning of Tuesday, July 9th, we received word that our surveyors were on site. After 4 days of survey including 2 days with an Engineer, 3 days with a Nurse surveyor and 4 days with our Physician surveyor we were pleased with our results and the engagement of our staff and providers.

Total, West Valley received 35 Requests for Improvement (RFI’s), with our surveyors averaging 3.8 RFI’s per day, just above the HCA average of 3.4 RFI’s per day. We were also congratulated with 17 best practices including a Fall Contract Program being driven by Laura Aldridge, Director Med/Surg/Peds, excellent Time-Out processes in our OR and procedural settings driven by Dr. Stritzke, Dr. Varley, Dr. Blaskiewicz and Dr. Box. Surveyors also noted excellence in hand hygiene in our Emergency Department setting and gave kudos to our use of the Accendo Wave as a non-opioid alternative for pain management.

The cleanliness of our hospital was impressive to all surveyors and we concluded our survey with zero EVS findings which speaks to the commitment of Carlos Vasquez, our EVS Director of 6 months. Our leadership team will spend the next few weeks working on our improvement efforts to validate with the Joint Commission when they return in August for a focused review. Thank you for your efforts not only while our surveyors were here, but every day as you are providing our patients care at West Valley. Below are areas in which you can impact our improvement efforts:

  1. Per our By-Laws, it is a requirement to document a patient’s medication list in your H&P’s. If a patient is not on medications, that must be noted.
  2. A legible signature, date and time is required on provider documentation.
  3. PRN medication orders need to be written with a symptom indicating administration, not a diagnosis. For example, Albuterol PRN should be written for wheezing, not asthma.
  4. Assessment and intervention for patients at risk for suicide.

We appreciate your engagement and efforts in driving high quality care for our patients and providing a safe environment of care for our staff. Please reach out to the leaders in your area or our Quality Department (208-455-6505) if you have any specific questions regarding our survey opportunities. Thank you for all that you do.

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