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HHC - New York Health and Hospitals Corporation - nyc.gov/hhc - Charlynn Goins, Chairperson - Alan D Aviles, President
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Patient Safety and Quality

Always Prepared For the Next Patient

Joint Commission

HHC hospitals have developed a reputation for excellence with the Joint Commission, the nation's premier healthcare accreditation organization, and this year's accreditation surveys of Bellevue, Queens, Harlem and Woodhull Hospitals continued to affirm what surveyors have commended in the past.

"One of the surveyors said that if he was in Queens and needed to be hospitalized, he would want to be taken to Queens Hospital," noted Caroline Jacobs, HHC Senior Vice President for Patient Safety, Accreditation, and Regulatory Affairs.

In 2004, the Joint Commission initiated a complete revision to their methods of surveying healthcare organizations for accreditation on a scheduled basis, and three HHC facilities - Queens, McKinney and Metropolitan - volunteered to pilot the new “unannounced” survey process. Beginning in 2005, the Joint Commission started to visit all hospitals on an unannounced basis, to assure that what they observed was indeed the type of care that was routinely provided. Other changes included introducing the "tracer methodology," in which surveyors select random patients and review the entire history of their care to insure that safety and quality standards were met in every department and with every procedure along the way.

"It's an effective way to move toward a more patient-centered approach that evaluates performance across departments not only during the few days that the surveyors are on-site, but also over a longer timeframe," added Jacobs.

All three of the hospitals who volunteered for the 2004 pilot passed their surveys with flying colors and every HHC hospital and nursing home has now received accreditation under the new unannounced process. The 2008 visits mark the beginning of the second round of unannounced surveys. In addition to Bellevue, Queens, Harlem and Woodhull, surveyors will visit Coler-Goldwater and North Central Bronx Hospitals this year.

The Joint Commission has adopted a list of 16 national patient safety goals, and each facility must demonstrate compliance with these standards, like consistent handwashing, medication reconciliation, and "time outs" before every surgery to insure that the right patient receives the right procedure on the correct surgical site.

The survey process also includes a more rigorous physical plant review, in which a Life Safety Code Specialist, a surveyor with engineering training, inspects the facility from roof to basement.

"The Joint Commission's new methods have raised the bar for us, but HHC's own quality and safety goals are completely aligned with the new process," said Jacobs. "We are always preparing for the next patient, rather than for the next survey."

June 2008




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