Quality Assurance

St.Vincent Dunn is pleased to share with you the details of our review by the Joint Commission.

Joint Commission

The Joint Commission is an independent body of medical reviewers that evaluates and accredits approximately 15,000 healthcare organizations in the United States.

Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. For more information on the Joint Commission, we invite you to visit their website: www.jointcommission.org.

Survey Process

During every Joint Commission visit, the surveyors are given complete access to the hospital and staff. The review is based on the treatment and care provided to patients to ensure quality and safety. If a concern is noted by a surveyor, an “RFI” (Required for Improvement) may be noted on the report. St.Vincent Dunn was happy to welcome the surveyors and open our hospital for their full review of our patient and safety processes.

The hospital was notified immediately after the review that accreditation would be granted for an additional three years. St.Vincent Dunn was reviewed according to the Accreditation for Critical Access Hospitals, of which there are greater than 200 standards.

List of Improvements

The following are a list of improvements noted by the Joint Commission.

Medication Management

Medication administration and disposition: Medications are properly and safely stored between receipt of a medication by an individual healthcare provider and medication administration.

St.Vincent Dunn Action Plan: Policy was developed regarding medication administration and disposition of medications that includes safe storage, safe handling, security and disposition of medications with return to the storage area.

Organizational Structure

Timeliness of reporting: Measure, assess and take appropriate action to improve the timeliness of reporting, and the timeliness of receipt by a responsible, licensed caregiver of critical test results and values.

St.Vincent Dunn Action Plan: Critical test report form has been developed that includes the times of ordering, resulting in physician notification of panic or critical test values.

Verbal and telephone orders: The critical access hospital complies with applicable law and regulation regarding the signing of verbal and telephonic orders.

St.Vincent Dunn Action Plan: Re-education of nursing staff was conducted. A stamp was also placed on each order form to assist with documentation of date/time of order documentation.

Thank you for taking the time to review our report. St.Vincent Dunn values the information received from the Joint Commission to improve our processes, thereby improving our patient care and patient outcomes. It is the goal of St.Vincent Dunn to provide quality healthcare with a commitment to excellence.