Ask Jill
06.25.2019

Does NMC undergo a quality of care audit?

Yes! NMC underwent our ‘every three years’ accreditation survey with the Joint Commission during the week of June 10. It is a very intensive process, with four surveyors (and two trainees) conducting a 4-day review of everything at NMC: the care we provide; our documentation; our credentialing and competency; our policies and procedures; our physical plant; and more. They scrutinize our main facility as well as our many provider practices and outpatient locations. We do not know exactly when they will conduct the inspection, so NMC operates in a ‘constant state of readiness’ and that was evident in the results of the survey.

I am so proud of how our entire team embraced this learning opportunity. I appreciate the consultative tone taken by the survey team, as that approach fosters open communication with staff and providers and increases the benefit of the time invested in this survey by all involved. With 6 experts (nurses, physician, facilities engineer) from across the country conducting a thorough review of nearly everything, one would expect there would be some findings. There were findings and they are resulting in improvements at NMC. Some were simple things with easy fixes that were addressed immediately, such as carts on wheels parked temporarily in front of fire extinguishers or medical gas valves. Some findings were a different level of learning and work flow improvement opportunity, and steps to address them are already underway, such as opportunities to improve our documentation and areas of the air handling system that need to be adjusted and expanded. At the same time, there were things the surveyors saw which they called out as exemplary – ranging from aspects of patient care all the way to staff, Board, and provider engagement. These findings and observations reflect an organization deeply committed to the mission of providing exceptional care for our community.

I have always been proud of our team. I am so pleased that they had this opportunity to shine and demonstrate the pride they take in our care and service. Our entire team’s engagement in our mission was evident to the surveyors. At the end of the process, the surveyors had high praise for the NMC staff and our organization.  Surveyors said, “You all have been a pleasure to work with.  You are truly a learning organization and have already jumped in and fixed things … You have a wonderful staff …You are doing an excellent job for your patients.”

In his closing remarks to a group of staff, managers, leaders, providers, and Board members, the physician surveyor shared two personal observations.  He appreciated NMC’s devotion to our community and the challenge of being independent, saying, “We have been surveying for quite some time now and have surveyed lots of hospitals across the country.  We don’t often see free-standing hospitals that serve their communities. So many have banded together into a system. We congratulate you for doing what you do.  Kudos to you.  The independent hospitals truly serve their communities.”  He also remarked at NMC’s commitment to a healthier future for all, saying “You have a wonderful aim of transforming healthcare from chronic disease and end of life care to all aspects of patient health and preventive medicine.  That is the solution to our healthcare crisis.” In the challenging times of healthcare system transformation, I truly appreciate both of those observations.

Once NMC receives the formal written survey report, we will file a response that identifies the improvements already made and our plans to complete those in progress. We will then have a validation survey to confirm the work has been done. This was a remarkable survey. Please join me in extending thanks and appreciation to the entire NMC team for a job well done.

— Jill Berry Bowen, RN, NMC’s Chief Executive Officer