Shady Grove Adventist Hospital Remains Fully Accredited Following Survey - Adventist HealthCare

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News Release

Media Contact: Tom Grant

Published on September 09, 2003

Press Release

Shady Grove Adventist Hospital Remains Fully Accredited Following Survey

Rockville, MD -  Shady Grove Adventist Hospital remains fully accredited following a one-day survey conducted by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) on August 15, 2003.

A surveyor from the Joint Commission reviewed the hospital's Intensive Care Unit (ICU) following reports that a nurse may have taken inappropriate action related to the care of a patient or patients. The nurse was immediately suspended by the hospital and has since been terminated.

The hospital has recently received a report from the Joint Commission following their one-day survey. (The State of Maryland also conducted a one-day survey on August 15 but the report has not been issued yet.) The Joint Commission report contains no deficiencies related to direct patient care, but does contain one deficiency (known as a Type I Recommendation) related to how data is collected and analyzed in the ICU.

"We are pleased that the report does not contain any deficiencies related to direct patient care, which we believe is a testament to the dedication, skill and commitment of our ICU staff and our physicians," said Deborah A. Yancer, President of Shady Grove Adventist Hospital. "We appreciate the feedback provided by the Joint Commission on the deficiency related to data collection. This is an area we had already identified as needing improvement and we are implementing corrective action in this area."

The hospital's formal accreditation level is "Accreditation with Requirements for Improvement." The hospital has six months to report on the progress it has made on correcting the one deficiency related to data collection. Yancer noted that corrective action is already underway in this area and the hospital expects to report back to the Joint Commission "well before the six month timeframe, perhaps within the next month or two."

Prior to the August 15 visit by the Joint Commission and the State of Maryland, the hospital, as part of its regular performance improvement initiative, had identified a number of strengths in the ICU, including experienced and competent staff, as well as staffing levels appropriate for providing a high level of care for patients. The hospital also identified action steps for further improvement.

The action steps, which already have been or are currently being initiated by the hospital, include:

  • Enhanced Staff Involvement in Decision Making: The hospital is creating three new nursing councils to provide ICU nursing staff with additional opportunities to be actively involved in establishing and reviewing clinical policies and procedures, as well as staff orientation and continuing education.
  • Identification and Tracking of Performance Indicators: The hospital is implementing a program to better utilize the data collected in the ICU to strengthen the department's performance improvement initiatives.
  • Enhanced Intensivist Coverage: Last year the hospital began a process to enhance coverage by intensivist physicians (specially trained physician support for critical care patients) in the ICU. The hospital is in the final stages of negotiating with a physician group and is targeting implementation for this Fall.
  • Policy Revisions: The hospital has revised several policies to enhance staff understanding and accountability. This includes the DNR (do not resuscitate) policy and the narcotic administration policy.
  • Organization Resources Supporting ICU: The hospital is clarifying the roles and responsibilities of some support staff in the ICU.
  • Enhanced Safety and Security in ICU: The hospital has installed additional cameras and implemented other security measures in the ICU.

"We always seek to review our quality of care in service to our community," said Deborah Yancer. "We appreciate the support and feedback from the Joint Commission and remain focused on providing the best possible health care experience for our patients."

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