Surveyors will be at Lawrence Memorial Hospital this week for an accreditation visit that comes only once every three years.
When Gene Meyer took over the reins as president and CEO of Lawrence Memorial repeated by hospital employees:
"Let's make Lawrence Memorial Hospital the best community hospital in the United States."
This week, Meyer sees an opportunity to move up another rung on the ladder in his quest. Three surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will spend Tuesday through Thursday at the hospital, poring over documents and meeting with staff members to rate the hospital.
A favorable survey by the nurse, doctor and administrator from the JCAHO is comparable to the Good Housekeeping Seal of Approval, Meyer said.
"I'd be less than honest if I didn't say that I hope we score very high on this, because it will be a good reflection on the quality of care our associates give," Meyer said.
"On the same hand, if by some chance we don't score as well, we want to make sure we take that and use it as a means of improvement," he said.
The nonprofit JCAHO surveys more than 18,000 hospitals, nursing homes, doctors' clinics and other health-care facilities at least once every three years. The organization, based in Oakbrook Terrace, Ill., releases a report within six weeks of the visit, and deficiencies will be reviewed at a six-month follow-up. Failure to comply with standards can be disastrous for a hospital: Medicare won't reimburse patients at nonaccredited hospitals, and most managed-care plans won't deal with institutions that fail.
Meyer, however, said JCAHO surveyors take steps to help instead of punish hospitals, and in-service seminars are often part of the fix.
"The joint commission has changed over the years, because hospital executives have said it's more of a punitive than helpful process," he said. "It's a kinder, gentler educational function they're serving. Part of their role is not only to make sure we meet those standards, but also to help educate our staff as to why those standards are important."
The joint commission is not only concerned with what the hospital has, but what it does, Meyer said. Surveyors aren't so concerned with the number of beds available as they are with the policies and procedures that affect patient care. An intense search of past records will tell surveyors how often and to what extent the hospital polices itself, including routine checks of equipment on the "crash carts" in the emergency department.
Both Meyer and Mindy Mitchell, director of LMH's clinical support services, have been through 12 JCAHO visits in their careers. Mitchell, who's in charge of preparing the hospital for the visit, has spent recent months studying the JCAHO's three-inch thick manual.
"They are very focused on processes. How do you assess the need for a new service? How do you determine your medical staff's needs and the community's needs, and then bring a new service on-line?" she said.
Mitchell said the hospital's new Magnetic Resonance Imaging unit and renovations to the second-floor hospital rooms won't necessarily translate to pluses in the survey, but the process used to establish them as priorities will be examined.
"They want to know how we make the decisions, and how we bring the departments together," she said.
Before the surveyors leave Thursday, they'll plug in laptop computers and punch in numbers on a score sheet. Hospitals are graded for 45 specific divisions in 15 areas, ranging from information management to patient rights. The laptops first came into use in 1996, Mitchell said.
The preliminary report, available to hospital administrators and board members at a "summation conference," will give Meyer an idea of how LMH fared.
"It used to be you'd wait two months, three months after the survey, and you didn't know how you did," he said. "It was really an incomplete feeling because you work really hard to do well, and other than some periodic feedback throughout the three days, you really didn't get an idea of how you did."
-- Chris Koger's phone message number is 832-7126. His e-mail address is firstname.lastname@example.org.