Yes. Patients and visitors at NMC may well have seen small teams of NMC staff accompanying surveyors on campus in late July. As part of NMC’s unwavering commitment to ensuring exceptional care for our patients, we proactively invite highly trained surveyors from Quorum, our national management company, to visit NMC for unannounced intense quality surveys. This is part of our ongoing readiness efforts relating to our formal accreditation surveys through the Joint Commission. While our official report will not be received for a few weeks, I am very pleased to report that the surveyors spoke very highly of NMC’s staff and our efforts, while providing very insightful, educational, and practical recommendations on how we can continue to improve what we do to keep pace with best practices and evolving regulations.
This “mock” survey covers all aspects of the care and service provided within the hospital itself, as well as the care provided at all of NMC’s employed physician practices and at our other satellite locations. Surveyors inspect policies and procedures, review records and documentation, and question staff to determine alignment with seemingly countless standards and regulations. Significant attention is given to infection control, staff training and provider credentialing, medication management, emergency preparedness, etc. The survey includes a very intense review of our physical “environment of care” to inspect every portion of the facility itself, ranging from patient care areas to “behind the scenes” spaces above the ceilings, in mechanical and boiler rooms, on the roof, and in storage and electrical rooms throughout the building. It is a remarkable process which involves a two to three member survey team over a three to four day visit.
The survey process is very thorough, interactive, and multi-faceted. A significant portion of the review of our clinical processes and care is structured around a “tracer methodology”. The Joint Commission defines this approach by saying, “The tracer methodology uses information from the organization to follow the experience of care, treatment, or services for a number of patients through the organization’s entire health care delivery process. Tracers allow surveyors to identify performance issues in one or more steps of the process, or interfaces between processes.” This approach moves the surveyor beyond the necessary step of reviewing policies and procedures to the even more beneficial approach of interacting with staff, physicians, and patients. They “trace” the path of a patient through their entire experience. It has proven to be very educational and really gets into the interdisciplinary nature of the care we provide. I am always proud to see our staff interact with the surveyors and hear them answer questions. Once a staff member gets past their initial nervousness, their knowledge and skill become very evident as does their compassion for our patients. The tracer approach really gives our staff a chance to shine and a strong opportunity to continue to learn.
The surveyors from Quorum have significant clinical backgrounds, strong expertise in healthcare quality, and extensive experience with regulatory surveys. They travel nationally assisting hospitals affiliated with Quorum with readiness for Joint Commission surveys. It is always gratifying to hear national experts like this say of our community hospital, “You have a lovely hospital and a nice staff, and patients are getting very, very good care here.” This reaffirms the hard work of the entire NMC team. The learnings and insights we glean from a survey like this energize our team to make continual improvements as we strive to fulfill our mission of exceptional care for our community. I would like to thank each member of our team for their devotion to quality care and service and their commitment to our hospital and our community. I am so proud of this team. On behalf of that entire team, I would like to thank Vice President of Quality Diane Leach and Quality Manager Nilda Gonella-French for guiding us through this important process as part of our ongoing commitment to quality. I would also like to thank each of you for your continued support of local healthcare in our community and for entrusting your care to Northwestern Medical Center. Please know that our entire team strives every moment to provide you with exceptional care.
— Jill Berry Bowen, NMC’s Chief Executive Officer