November 15, 2009
Joint Commission finds few problems at YKHC
by Jeffrey P. Murchison, Performance Improvement/Compliance Administrator
YKHC is accredited by the Joint Commission, which evaluates hospitals in accordance with specific standards. The standards are very comprehensive. YKHC has three accreditations-the Hospital, Behavioral Health and Home Care. The Centers for Medicaid and Medicare (CMS) also have specific standards called "Conditions of Participation." The Joint Commission and CMS standards are linked. That means we must comply with both standards in order to bill Medicaid and Medicare for the services we provide to our patients.
Every year our organization evaluates our compliance with respect to our three areas of accreditation. This evaluation is called a Periodic Performance Review (PPR). Every three years the surveyors from the Joint Commission visit our organization and evaluate our compliance with respect to their national standards. On October 20, 2009, five surveyors arrived to perform their evaluation. They desired not only to evaluate the services we provide in Bethel but also the service delivery in our village clinics and our subregional clinics. They divided up their team, charted a plane and visited Hooper Bay Subregional Clinic, Scammon Bay Village Clinic and the Betty Guy Clinic in Kwethluk.
The surveyors divide the standards into two categories, direct (standards directly affecting patient care) and indirect (standards not directly related to patient care). The Joint Commission standards are designed to allow the organization to demonstrate compliance over time. It is not possible to start today and demonstrate compliance tomorrow. It takes leadership, teamwork and commitment to ensure our efforts not only are in compliance with the standards but lead to the best outcomes in patient care.
Of the thousands of standards reviewed in all three accreditation areas (Home Care, Behavioral Health and the Hospital) the following numbers of deficiencies were noted:
Hospital: Five direct deficiencies and 13 indirect deficiencies.
Home Care: One direct deficiency and no indirect deficiencies.
Behavioral Health: No direct deficiencies and three indirect deficiencies.
Of the deficiencies noted above, six of them were identified and reported to the Joint Commission in our Periodic Performance Review submitted September 4, 2009. Action plans had already been created and were in the process of being implemented.
Sometimes at a glance it is hard to know how hard everyone works to provide and continuously improve patient care. We did well according to the Joint Commission. We thank everyone for their dedication and service. Most importantly, we thank you, our patients, for allowing us to opportunity to serve you.
