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King's
Daughters Medical
Center in Brookhaven, MS
has earned The Joint Commission's
Gold Seal of Approval™
for accreditation by demonstrating
compliance with The Joint
Commission's national standards
for health care quality
and safety in hospitals.
The
accreditation award recognizes
KDMC's dedication to continuous
compliance with The Joint
Commission's state-of-the-art
standards.
KDMC
underwent a rigorous unannounced
on-site survey by a team
of Joint Commission expert
surveyors that evaluated
KDMC for compliance with
standards of care specific
to the needs of patients,
including infection prevention
and control, leadership
and medication management.
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In
achieving Joint Commission accreditation,
Kings Daughter's Medical Center
has demonstrated its commitment
to the highest level of care for
its patients," says Mark
Pelletier, R.N., M.S., executive
director, Hospital Programs, Accreditation
and Certification Services, The
Joint Commission. "Accreditation
is a voluntary process and I commend
KDMC for successfully undertaking
this challenge to elevate its
standard of care and instill confidence
in the community it serves."
"With Joint Commission accreditation,
we are making a significant investment
in quality on a day-to-day basis
from the top down. Joint Commission
accreditation provides KDMC with
a framework to take our organization
to the next level and helps create
a culture of excellence,"
says Alvin Hoover, CEO. "Achieving
Joint Commission accreditation,
for our organization, is a major
step toward maintaining excellence
and continually improving the
care we provide."
Since its founding in 1951, The
Joint Commission has been acknowledged
as the leader in developing the
highest standards for quality
and safety in the delivery of
health care, and evaluating organization
performance based on these standards.
Today, more than 19,000 health
care organizations use Joint Commission
standards to guide how they administer
care and continuously improve
performance. The Joint Commission
is also the only accrediting organization
with the capability and experience
to evaluate health care organizations
across the continuum of care.
The Joint Commission has accredited
hospitals for more than 60 years
and today it accredits approximately
4,168 general, children's, long
term acute, psychiatric, rehabilitation
and specialty hospitals, and 378
critical access hospitals, through
a separate accreditation program.
Approximately 82 percent of the
nation's hospitals are currently
accredited by The Joint Commission.
Eligibility
Any health care organization may
apply for Joint Commission accreditation
under the Hospital Accreditation
Standards if all the following
requirements are met:
o The organization is in the United
States or its territories or,
if outside the United States,
is operated by the U.S. government,
under a charter of the U.S. Congress.
o The organization assesses and
improves the quality of its services.
This process includes a review
of care by clinicians, when appropriate.
o The organization identifies
the services it provides, indicating
which services it provides directly,
under contract, or through some
other arrangement.
o The organization provides services
addressed by the Joint Commission's
standards.
o If the organization uses its
Joint Commission accreditation
for deemed status purposes, the
organization meets the Centers
for Medicare & Medicaid Services
definition of a "hospital."
Benefits of
accreditation
Hospitals seek Joint Commission
accreditation because it:
o Helps organize and strengthen
patient safety efforts.
o Strengthens community confidence
in the quality and safety of care,
treatment and services.
o Provides a competitive edge
in the marketplace.
o Improves risk management and
risk reduction.
o May reduce liability insurance
costs.
o Provides education on good practices
to improve business operations.
o Provides professional advice
and counsel, enhancing staff education.
o Provides a customized, intensive
review.
o Enhances staff recruitment and
development.
o Provides deeming authority for
Medicare certification.
o Recognized by insurers and other
third parties.
o Provides a framework for organizational
structure and management.
o May fulfill regulatory requirements
in select states.
Standards
Joint Commission standards address
the hospital's performance in
specific areas, and specify requirements
to ensure that patient care is
provided in a safe manner and
in a secure environment. The Joint
Commission develops its standards
in consultation with health care
experts, providers and researchers,
as well as measurement experts,
purchasers and consumers. The
current standards-based performance
areas for hospitals are:
Environment of Care
Emergency Management
Human Resources
Infection Prevention and Control
Information Management
Leadership
Life Safety
Medication Management
Medical Staff
National Patient Safety Goals
Nursing
Performance Improvement
Provision of Care, Treatment,
and Services
Record of Care, Treatment, and
Services
Rights and Responsibilities of
the Individual
Transplant Safety
Waived Testing
Survey process
To earn and maintain accreditation,
a hospital must undergo an on-site
survey by a Joint Commission survey
team. The survey team can include
one or more health care professionals,
including a physician, nurse,
life safety code specialist, or
hospital administrator who has
senior management level experience.
Joint Commission surveys are unannounced,
with a few exceptions. An organization
can have an unannounced survey
between 18 and 36 months after
its previous full survey. For
example, if an organization's
last survey was January 1, 2009,
it could have its survey as early
as July 1, 2010 or as late as
January 1, 2012 (18 to 36 months).
A
survey is designed to be individualized
to each organization, to be consistent,
and to support the organization's
efforts to improve performance.
During an accreditation survey,
The Joint Commission evaluates
an organization's performance
of functions and processes aimed
at continuously improving patient
outcomes. This assessment is accomplished
through evaluating an organization's
compliance with the applicable
standards in the manual, based
on the following:
o Tracing the care delivered to
patients
o Verbal and written information
provided to The Joint Commission
o On-site observations and interviews
by Joint Commission surveyors
o Documents provided by the organization
Performance
measurement requirements
The Joint Commission's ORYX®
initiative integrates outcomes
and other performance measurement
data into the accreditation process.
ORYX measurement requirements
are intended to support Joint
Commission accredited organizations
in their quality improvement efforts.
In 2002, accredited hospitals
began collecting data on standardized
- or "core" - performance
measures. In 2004, The Joint Commission
and the Centers for Medicare &
Medicaid Services began working
together to align measures common
to both organizations. These standardized
common measures, called Hospital
Quality Measures, are integral
to improving the quality of care
provided to hospital patients
and bringing value to stakeholders
by focusing on the actual results
of care. Measure alignment benefits
hospitals by making it easier
and less costly to collect and
report data because the same data
set can be used to satisfy both
CMS and Joint Commission requirements.
Should you have any concerns about
patient care and safety in this
hospital that the hospital has
not addressed, you are encouraged
to contact Alvin Hoover, KDMC's
Chief Executive Officer, by calling
(601) 833-6011.
If
your concerns cannot be resolved
through the hospital, you may
contact the Joint Commission on
Accreditation of Healthcare Organizations
by writing:
Office of Quality Monitoring
Joint Commission on Accreditation
of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Telephone (800) 994 - 6610
Emailed to complaint@jointcommission.org
