The information in these profiles is gleaned from TJC-provided biographical material, peer facilities and other internet sources. The opinions expressed are not necessarily those of F&A but are made available as peer feedback that may assist with your surveyor communications and interactions. This information is not for publication or distribution beyond SHCC membership and should be used with appropriate discretion and felicity. The integrity of our collaboration depends on this. Thank you.
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Walter Diggs Administrator Surveyor Walter Diggs is currently a resident of Tennessee.He received a Bachelor of Science degree from Washington & Lee University and a Masters degree in Hospital Administration from the University of Minnesota.
Prior to joining the Joint Commission, Mr. Diggs was Assistant Director, Wilmer Eye Institute, The Johns Hopkins Hospital; Administrator, Medical College of Georgia Hospital and Clinics; Chief Executive Officer, Health Systems Management; and Superintendent Memphis Mental Health Institute.He was also associated with the City of Memphis Hospital, Chelsea Naval Hospital in Boston, and Stormon-Vail Hospital in Topeka, Kansas. He has held faculty appointments at the Medical College of Georgia in community Medicine, Georgia State University in Hospital Administration, Georgia Tech in Systems Engineering, the University of Memphis in Political Science, and the University of Tennessee in Community Medicine, Family Medicine, Psychiatry, and the Graduate School.He has published more than twenty papers including more than ten papers on performance and outcome measurement. Diggs is a Life Fellow in the American College of Health Care Executives.He has served as a consultant to the Tennessee Department of Mental Health and Mental Retardation. Diggs has been a Joint Commission surveyor since from 1981 - 1988 and 1993 to the present.He surveys the Standards in the Accreditation Manual for Hospitals, and served as a Regional Representative for the Tennessee Continuous Survey Readiness Program. {ZoomInfo 2005}
Comments/Rec:
• 6/19/09: Administrator - he focused on measuring outcomes through the use of the GAF score; he also focused on patient safety and culture of safety within the entire hospital system. Recent Survey History: 6/19/09@TSH/PSQ,
Comments:
Understanding, cooperative. Very interested in keeping the facility best interests in mind. Tried to teach resolution if a problem was found.
• 12/8/09: VERY easy to deal with and helpful. He took more of an educator role. From TN and stated there are minimal architech/engineers in this region so we surmise he may be visiting several of our state hospitals
• Jan 2010: Thorough in checking records but not picky. Gave good advice while going through the building.
Michael T. Chisholm, CPE -Life Safety Code Specialist
TJC Bio (x 20??)
Sureys: Accreditation Manual for Hospitals
Lives: South Carolina
Work:
Director of Safety and Security at Medical College of Georgia Health, Inc
AFE Certified Plant Engineer
Comments:
• Very knowledgeable, thorough, fair and helpful (e.g., provides a list of the documents/equipment needed for his building tours). Gives lots of suggestions.
• Michael Chisholm/3/10 only/environmental -thorough but fair
Rec:
•Don't have to agree to impliment them, but accept suggestions gracefully.
Mr. Giovinazzo is currently an Associate Executive Director for Network Facilities Management at Metropolitan Hospital Center, New York City, New York.
Mr. Giovinazzo maintains certification as a licensed New York City Master Electrician.
• ? Safety and Risk Officer at Natividad Medical Center, Salinas, California (www.natividad.com/), 172-bed acute care medical center
• ? Sharp Healthcare Corp.
Comments:
• 3/12/10: Conducted tracer and survey activities in environment of care, life safety and emergency management. Mr. Kitagawa had a very brief amount of time to run through his area of expertise as he had only one day for his part of the survey, part of which is spent working up the report. He moved very quickly through his task, but was also very thorough. He was very pleasant, had a easy going jokey demeanor. He was able to spot relevant problems in our environment quickly. He also was easy to engage and was open to questions outside of his findings.
• Very educational in his approach, giving an explanation and a practical example, very congenial. Helpful not only in Life Safety but all Environment of Care.
Rec:
• Contributed to the The National Association of Psychiatric Health Systems (NAPHS)Design Guide for the Built Environment of Behavioral Health Facilities:
William H. McCully, CHFM -Life Safety Code Specialist
TJC Bio (x 2007)
Sureys: Accreditation Manual for Hospitals
Lives: ARK
Work:
• 7/24/09: Quiet, particular, stands his ground
• 4/21/09: Very thorough - used the ladder and the flashlight
• 2007: Director of plant operations and maintenance at the Northwest Medical Center of Washington County in Springdale, Ark. {ZoomInfo}
• Mr. McCully is a Certified Healthcare Facilities Manager and holds Senior status in the American Society for Health System Engineering {TJC09}
Comments:
• Nov 2010: Very thorough and knowledgeable. Friendly and complimentary regarding our newer facility. Covered every inch of the building.
• Aug 2009: Thorough tour of the facility, did not key in on one specific area of the LSC, rather covered all aspects. Educational and consultative regarding issues surrounding the LSC.
• May 2009: Pleasant and thorough.focused on Infection Control Disaster Planning
Comments:
Very strict, focued on handwashing, IC, Competency. Focused heavily on 1-2 staff members once found a problem in an area and was relentless in the tracer.
Comments:
3/13/09: Mr. Samples had been in a hospital fire at one time in his career so was quite focused on safe escape in case of fire. He looked at all exits from every angle and monitored hallways to make sure there weren’t any fall hazards in case of smoke/fire. Mr. Samples was helpful in that he educated staff, not only on standards compliance, but on other steps we could take to make the environment safer.
----Focused on the task at hand - cuts no slack on issues.
----- he was not included on the TJC visit agenda when it posted – he came in on the very last day of the survey – he lives here locally in Fairhope, AL – states he now works full time for TJC
• 6/19/09: he was thorough in his review of the physical plant.
• FEb 2009: Life Safety Code Specialist, Most of our RFIs came from the LSC specialist. He didn't miss a thing. Very knowledgeable about the standards and spent time giving us lots of tips, but in the end, he cited us for everything he found. Focus: penetrations, ILSM.
• I did not spend much time with him but this is my second survey with him also and he is very tough. He will also teach and consult if allowed.
• Re: 8/21/08 - Very thorough, lots of good suggestions
George L. Thomas, CHFM, FASHE -Life Safety Code Specialist
TJC Bio (x ???)
Sureys: Accreditation Manual for Hospitals
Lives: NJ?
Work:
• 2008: Appointed chair of Public Relations Committee of Healthcare Facilities Management Society of New Jersey, Inc. and to Engineering Advisory Board of the New Jersey Hospital Association; {http://www.hfmsnj.org/pages/Minutes/20080117minutes.html}
Mark A. Trudzinski, M.Ed., SASHE, CHFM, CPMM- Life Safety Code Specialis
TJC Bio (x 20??)
Sureys: Accreditation Manual for Hospitals
Lives: Texas
Work Hx:
Deputy Chief of Staff for Engineering and Facility Management US Army Medical Dept. Center and School. {Zoom Info}
Comments:
• May 2009: Proficient and knowledgeable in all aspects of his area of expertise. Demonstrates an understanding of the intent of the standards and practical application.
• Extremely knowledgeable. Focused on detail.
• Went places and found things that nursing surveyors doing the environment never even thought of doing
•
Rec:
• Be sure to have clear records of all required EC testing
Charles W. "Bill" Wensyel, P.E., C.E.M., Life Safety Code Specialist/Engineer
TJC Bio (x 2009)
Sureys: Accreditation Manual for Hospitals & Critical Access Hospitals
Lives: PA
Work/:
Prior to joining The Joint Commission, Mr. Wensyel was the System Director, Engineering at Heritage Valley Health System located outside Pittsburgh, PA.
Mr. Wensyel is a Registered Professional Engineer in the Commonwealth of Pennsylvania and the State of West Virginia.
He is also certified with the Association of Energy Engineers as a Certified Energy Manager.
Comments:
3/24/10: Focused on transfer switch logs, fire extinguisher checks having a date and went up into almost every ceiling space he could see. Very thorough and friendly.
• Questioned staff in every role. Clinical focus was on continuity of care. Hard questions in the PI session. EC focus was on disaster drills and ability to function in place for4 days (96 hrs) without outside help.
Ms. Bumpass is the Quality Manager at the Federal Medical Center in Butner, N. C.
Ms. Bumpass is currently licensed in North Carolina as a Registered Nurse.
Comments:
3/24/10: Focused on Infection Control, Direct Care Staffing, Falls, Competencies, Medication, Critical Radiology Tests. Tips-Quiet at first, does quick tracers and fires off questions quickly. If answer intelligently and quickly will quickly change directions. Warmed up to staff by third day. Very thorough and fair.
*More info/feedback is needed on this surveyor. To add your input, click here or use our online form to add your input atwww.shccPSQ.com. Thank you.
TJC Bio
•
Comments
• 7/2/09: Likes to talk about research and data. Talks a lot about previous experiences in military and as an OR nurse. Likes having thoughtful discussion and does well at putting staff at ease during interview. Seems to take pride in feeling like he's providing consultation and helping staff and leadership understand standards and rationale for RFIs. Very thorough. Solicits feedback, but doesn't always listen. Seems to know a little about everything, including Life Safety Code, food preparation requirements, etc. Really focused on the assessment of safety risks throughout the survey.
• 3/8/08: 23 years in Military shows. Very straight forward. Very precise. Focus was on EOC and plans. Gave many suggestions as to how to improve plans. Looked for "spirit" of the law. Was obviously influenced by surveys before ours and I think that helped. Liked that we had things together and he did not have to ask or look. We had all of the things in the activity guide there plus bylaws and plans (PI and Plan of Care. I felt he was overall fair but not someone you want to argue with.
Rec:
• Provide him with the info (data) and give him time to make up his own mind.
Served as Director of Psychiatric Services for adult and adolescent hospital based programs in Illinois and Wisconsin.
Served as lead clinician, program manager, educator and systems integration specialist for community based MH programs in Illinois.
Ed/Train: She is board certified in psychiatric/mental health nursing.
Comments
3/12/10: conducted tracer or survey activities in patient care, infection control, human resources, information management, leadership, medication management, waived testing, and NPSGs Very positive in her interactions, educational and willing to talk through findings and expectations. Very engaging in a pleasant and non threatening way.
11/20/09:
Friendly, easy going but very knowledgeable. Focuses on issues pertinent to nursing - will allow leadership to provide additional information if something needs clarifying even during interactions with line staff. Many years experience in the behavioral health system. A dedicated history buff.
She has an extensive background working in behavioral health settings. She is very pleasant to survey with, very knowledgeable about her area, and is very patient oriented. She truly enjoyed interacting with our clients on the unit – becoming … emotional during an interview when the client was describing his home situation to the point she had to end the interview early to regain her composure. She is very down to earth and appears to really enjoy the accompaniment of fellow nurses during tracer activities.
• 5/17/07: Psychiatric Nurse Surveyor; also conducted EC survey. Wants coffee available all day long. Aside from tracer findings, focused on external disaster preparedness, competencies (looked for breathalyzer specifically) and wants measurable performance indicators in disaster drills. Wants disaster drills that really strain the systems; pharmacy, dietary, etc., communications, etc. Both surveyors (Hanson & Flocks) felt that a medication pass in a psychiatric hospital, where patients line up to receive a cup, is “direct patient contact” and thus requires handwashing between each medication ;pass. During discussion of CDC guidelines, they both independently stated that a nurse should not need to think about whether skin contact occurred; should just automatically wash between every patient
TJC (x 1994)
Siward Hazelton is currently a resident of Dalton, Massachusetts. He received his Bachelor of Science degree in Nursing at the University of Connecticut in Storrs, Connecticut and his Master of Art degree in Healthcare Administration at the Hartford Graduate Center in Hartford, Connecticut.
Prior to joining the Joint Commission, Mr. Hazelton was Vice President of Nursing and Patient Care Services at Providence Hospital in Holyoke, Massachusetts; Director of Patient Information Services at Berkshire Medical Center in Pittsfield, Massachusetts; Director of Medical Records and Quality Management at the University of Connecticut Health Center in Farmington, Connecticut; Nurse Manager of Pediatrics, also at the University of Connecticut Health Center; and Staff Nurse of Pediatrics ICU at Yale New Haven Hospital in New Haven, Connecticut.
Mr. Hazelton has been a Joint Commission surveyor since 1994 and is trained under the Accreditation Manual for Hospitals and survey Rehabilitation Hospitals.
Sureys: Accreditation Manual for Hospitals, Long Term Care Home Care, Behavioral Health
Lives: Arcadia, CA
Ed/Work:
• Associate of Arts degree in Nursing: Pasadena City College, CA
• Master of Arts degree in Human Resource Management: University of Redlands, CA
• Past Work includes Head Nurse of Labor & Delivery, CCU/ICU staff nurse, Nursing Educator , Quality Coordinator, DRG Coordinator and Mangement/Leadership trainier in both acute and log term care settings.
• Current Position: VP of Education and Development for a long term care company
• Areas of Expertise: critical care, infection control, QI/PI, corporate compliance
Misc:
• Member of Organization of Healthcare Educatrs, Sigma Theta Tau (Society for Quality and Improvement)
• During September 2007 survey of a private psychiatric hospital she asked about:
> our two patient identifiers.
> She wanted the MR labels on all of the med drawers (not just a piece of paper that said the patients name). [I did fix this while she was there and she was okay with it.]
>She also wants the blister packs of medications in a bag labeled with the patients name (to come from pharmacy).
> She does not like the individual bottles that come from pharmacy that have the medication but NOT the patients name on them.
> She asked us about pre-pouring which we said we do not do
> Fire drill process
> Disaster drills, recommendations and actions How are we linked to the community during a disaster?
> Emergency privileging in a disaster
> What improvements have we made in the past 6 months
>She noticed a number of falls so she asked about our fall risk program
> How do we handle security?
> Do our safety officers attend behavior management training?
> Tell me about your medical equipment program Is there a regular schedule of checks on equipment?
> She finished up by reviewing fire safety documents and generator logs.
> Wanted documentation r/t R&S, Behavior management, de-escalation training.
> Very methodically going over 3 patients tracers in which she asked for 3 different diagnoses, Eating disorders, Dual Diagnosis, and Major Depression on the Eating Disorder patient
> She chose a restraint and seclusion patient and a recent admission, chose a restraint and seclusion patient and a recent (not yesterday) admission,
• 6/19/09: Nurse Surveyor - she focused on medication administration, and documentation in the record to support needs identified in assessments (continuity of care).
• Feb 2009: Was in trainee role. Tips: Much harder to convince but could be convinced on some level. VERY knowledgeable about the standards: you won't get much by her. She focused on NPSGs, Infection Control and the medical care of patients- not much psychiatric focus (unfortunately since that's our specialty). She was easy on Staffing Effectiveness, Data and Human Resources. Many of our RFIs came from her observations. She was a great consultant.
Surveys: hospitals, behavioral health, substance abuse and forensic facilities.
LIves: Illinois
History
• Prior to joining the Joint Commission in 1986, Ms. Jordan worked as Assistant Director of Nursing for St. Anne’s Hospital, Chicago, Illinois, as Director of Nursing/Director of Clinical Services at Old Orchard Hospital, Skokie, Illinois, and as Assistant Professor at Loyola University School of Nursing, Chicago, Illinois. {TJC09}
• Ms. Jordan has been a Department Head in medical/surgical and psychiatric facilities, and an Assistant Vice-President for Performance Improvement/Regulatory Compliance (corporate position) for a national psychiatric organization with 50 hospitals throughout the United States. Ms. Jordan has also had clinical work experience including general medicine/surgery; child, adolescent and adult behavioral health and substance abuse. {TJC09}
Misc:
• She received her Bachelors degree in Education and Nursing from Fitchburg State College, Fitchburg, Massachusetts, and her Masters in Psychiatric Nursing from Boston College, Boston, Massachusetts. {TJC09}
• Ms. Jordan is affiliated with the American Board of Quality Assurance and Utilization Review Physicians, (ABQAURP) as a diplomate, and the Association for Practitioners in Infection Control {TJC09}
Comments: • Nove 2010: Spent 2 days for the Hospital Accrediation and 2 days on the Behavioral Health Accreditation. Her attention focused towards contract staffing and towards critical tests and diagnostic procedures
• Aug 2009: Sharp & thorough. Keyed in on competencies and data-driven decision making. Consultative throughout the process, very open about observations made (some were cited, many were not).
• May 2009: Would get focused on one issue.
• A good consultant fairly solid but may have the ability to be a bit rigid. She tends to focus on competencies/competence criteria (documentation of the method used to verify each competency is important to her.), infection control, coordination/integration of services, and looks carefully at behavioral management programs. Recs:
Have printed joint commission FAQ's and published competency guidelines from recent JCR publications to back up the org's approach to competencies.
Prior to joining the Joint Commission, Mrs. Kateiva had been the vice president of Quality and Care Management, Ochsner Clinic Foundation, New Orleans, Louisiana; Vice President Operations, Ochsner Foundation Hospital, New Orleans, Louisiana.
Joan’s 12 years of military nursing experience involved critical care and medical surgical patients.
Mrs. Kateiva is currently licensed in Louisiana as an RN.
Mrs. Kateiva also maintains membership in the American College of Health Care Executives.
Comments:
3/24/10: Focused on primarily medical issues and Leadership role. Focused on the role of governing body and how the organization chart is designed. Overall friendly, very professional, somewhat military style in approach, direct but fair.
Sureys: Accreditation Manual for Hospitals, Integrated Survey Process forRehabilitation Hospitals, is assigned to work in the Special Survey Unit
Lives:
Work:
Clinical Staff, and hospital management/administrative positions. Aassistant professor in Nursing Education.
Ed/Train:
BS Degree in Nursing from Ohio State University, Masters Degree in Nursing from the University of South Carolina.
Other:
Her professional affiliations include the American Nurses Association, the National League for Nursing, the American Organization of Nurse Executives, and Sigma Theta Tau. The American Society of Professional and Executive Women recognized her in 1987, and Who’s Who in American Nursing in 1989.
Work: administrative and educational positions in anesthesia; executive level hospital acute care, ambulatory, nursing and perioperative programs. A large portion of his career was at The Queen’s Medical Center in Honolulu, Hawaii. Most recently, he was a Vice President at Trinity Mother Frances Health System in Tyler, Texas and immediately prior to this position, he served as an Executive Director at Columbia Presbyterian Medical Center, New York, New York.
Other: Registered Professional Nurse (R.N.), and member of the American College of Healthcare Executives.
… is currently a resident of Kaysville,Utah. Mr. Koenen has been a Joint Commission surveyor since 2005, and is trained under the Accreditation Manual for Hospitals. Mr. Koenen is presently a full time surveyor in the Hospital accreditation program. Mr. Koenen owns a retail business in Utah when not working for the Joint Commission Accreditation Healthcare Organizations. He is a Colonel in the USAF Retired Reserve. He was active as a senior nurse surveyor for the Air Force Inspection Agency for over seven years prior to joining the Joint Commission Accreditation Healthcare Organizations. He had been a Chief Nursing Officer and the Chief of Clinical Services for two large health care organizations over the past ten years. Mr.Koenen is currently licensed in Utah as an RN. He is a Diplomat in the American College of Health Care Executives.
He's a teacher -Focus EOC, very thorough building tours,unlocked fences and inspected all generators -Likes direct answers, little patience for BS -1st day very much about business, warms up after 2nd day
2009: Ms. Krone has held leadership, research, educational, and clinical positions at the University of Michigan Hospitals and
Health Centers, and has been on the faculty of the University of Michigan School of Nursing. She has also held the
position of Nurse Director for Behavioral Health Services at Chelsea Community Hospital in Chelsea, Michigan. Ms. Krone is
a Past President of the American Academy of Ambulatory Care Nursing. {TJC Bio}
2005: President, American Academy of Ambulatory Care Nursing (My name is Kathy Krone and I AM an ambulatory care nurse!! And I am so excited to serve as president of this wonderful organization.) {ZoomInfo}
Comments:
• April 2009: Kathy was with us for our 2006 survey. Very knowledgable and fair.
• Jan 2010: Team Leader - Very personable; interacted and joked with all levels of staff. She was very efficient and moved along quickly. On the programs, she was very focused on (and impressed with) the knowledge base of mental health workers and nurses regarding the treatment plan and diagnoses for each patient. During individual tracers, she focused on how we 1) collect, document quality control and reference range information for glucometers; 2) document "Read Back done" on phone orders; and 3) transcribe physician orders. Checked the medication rooms (looked at expiration dates on vials, whether orderly and clean) and asked some medication questions while observing two LPN's during medication pass with attention to the two patient identifiers. Focused on hand hygiene. Actually asked mental health workers to show their individual hand sanitizer. Looked at hand hygiene PI data.
Associate Director, Standards Interpretation at the Joint Commission.
TJC Bio (x 2004)
Surveys: Accreditation Manual for Hospitals and the Behavioral Health Care Manual
Lives: Texas
Work:
• Ms Leslie has over 24 years of experience in nursing.
• Prior to joining the Joint Commission, Ms Leslie has held nursing administrative and operational leadership positions in healthcare organizations. She has also been a Nursing Instructor.
• As an Assoc Director, she provides interpretation of standards, serves as faculty for surveyor and other education programs, conducts Periodic Performance Review conference calls, and consults in the development of standards and survey processes.
• Ms Leslie is currently licensed in Illinois and California as a Registered Nurse. She also maintains certification in Psychiatric and Mental Health Nursing.
• Ms Lisa served as chief nurse executive for over 20 years in both for profit and non profit hospitals. Prior to joining the Joint Commission, Ms Lisa was Vice President of Patient Care at Canton-Potsdam Hospital at Potsdam, New York.
• Ms Lisa served 10 years on active duty as a nurse in the USAF and she is retired from the Air Force Reserves.
Comments:
• Highly focused on medication management. She had us make a case for a finding when she found 1 HR chart each not up to date on mandatory TB tesing or CPR training - she asked us to find 3 more records. (We were able to get this finding removed.)
We had Valetta Love in February 2006. Her background is psychiatry and rehab. She focused in depth on psychiatry issues. (We are a general hospital with a psych unit). She was also very focused on infection control and HR standards including: orientation, competency and staffing effectiveness. VERY THOROUGH, but fair I thought. - with permission of D. Phillips, Wayne Health 7/9/07
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Very strict, focued on handwashing, IC, Competency. Focused heavily on 1-2 staff members once found a problem in an area and was relentless in the tracer.
Assistant Vice President for Nursing and Service Line Manager for Neuroscience at the Methodist Hospitals in Merrillville and Gary Indiana.
diploma in Nursing from South Chicago Hospital School of Nursing, a Bachelor of Science in Nursing from Lewis University, Lockport Illinois and a Master in Public Administration from Indiana University, NW
Her background is in Critical Care areas of Neuroscience, Cardiac and Trauma
Comments:
•She admits not much psych background and she tends not to delve into psych issues. Rather focuses on medication management, med errors (may ask what is your most common med error), PI implications of data, contracts. Very safety minded and very observant. Wants to see pt ed documented in chart. Likes to teach.
Rec:
•Let her teach. She sometimes allows org to pick patients so be prepared. Dosen't like a large entourage so limit her escorts and use medically oriented staff
• May 2009: Very familiar with the challenges associated with psychiatric treatment. She has a background of working is a state operated psychiatric facility. Personable, reasonable, and realistic.
Very important that our nursing director established a close relationship with her and was willing to disclose areas of concern
• Nancy Paterson, MS,RN-3/9-3/12-nurse surveyor/tracers/IC/table top exercise/competency review of personnel records-very gracious and fair, really put staff at ease so they could tell and show what they knew
Sureys: Accreditation Manual for Hospitals and Critical Access Hospitals
Lives: Ohio
Work/:
Previously:
Comments:
• March 2009: Has worked in QI/QC role, Emphasis on measurement of baseline and improvement
• Prior to joining The Joint Commission, Ms. Schindler was Staff Nurse and held various staff nursing and nursing management positions. She was a Faculty Member at two diploma nursing programs in Ohio. She was Vice President of Patient Services for Elyria Memorial Hospital in Elyria, Ohio
• She received her Diploma in Nursing from Bethesda Hospital School of Nursing in Cincinnati, her Bachelor of Science degree in Nursing from Ohio State University and her Master of Education degree from Kent State University in Kent, Ohio.
• Re: 8/21/08 -Very direct, no nonsense, always on point with standards
• Linda Sellers, RN, has been appointed to the position of nurse executive at Mississippi State Hospital in Whitfield. Sellers comes to MSH from the JCAHO where she served as a surveyor and consultant. Sellers still serves as an intermittent JCAHO consultant. She brings more than 12 years of experience to her new position. She earned her nursing degree from the Toledo Hospital School of Nursing in Ohio. She also holds a bachelor’s degree in public affairs and a Master of Education from the University of Toledo. [2004 MHA]
Comments:
• 5/21/09: thorough but fair/ Couldn't say what her primary focus was, covered a lot of ground/ knowledgeable and experienced
• 4/21/09: Focused on Environment of Care, Human Resources, Data Use Tracers: Infection Control, Emergency Management, Provision of Care / Ms. Sellers was organized, efficient, competent, thorough, and professional with no personal agendas that we could determine.
·In Data Use Session – Nurse takes strong role in this session
otalked to staff about the “Red Dots” on the ORYX report and wanted to know what SELH had done about them
owanted to know if pts were asked about pain each shift.
oasked each person in the room what kind of data they collect.o
·x Looked for patient to trace (Nurse stated she usually picked by Diagnosis & DOA)
·Basically read the entire chart.
·Re Leadership Session
oLynne said if you fill a big room she expects a lot of comments.
oAsked which is biggest challenge: staffing, communication or changing performance
·x Asked about use of plastic bag in trash cans.Noted one area that had a plastic bag but was in an area blind to observation AND accessible to patients
·Re: Competency Session
o5 records reviewed (2 were contract employees):Primary source verification for nurses, respiratory therapist, and dietician.
oJob descriptions reviewed – to be signed upon hire.One SW’s was not signed, one agency nurse did not have a job description.
oWanted to see record of general orientation.Where is NPSG taught?Who requires CPR? Where is this specified?Do social workers have to have CPR?Show me where the policy states SW do not need CPR.
TJC Bio
ANCC certification as a Psychiatric and Mental Health Nurse. Prior to joining JC was the administrator, Chief Clinical Officer and Risk Manager for Centennial Peaks Hospital in Louisville, Colorado.
RN licensed in Colorado, Texas, and California
Comments
Very pleasant and easy to work with. Recognizes the challenges of acute psychiatric care and showed patience as we identified the manner in which we satisfied standards.
Ms. Snyder has been a surveyor with the Joint Commission since 2005, and surveys in the Accreditation Program for Hospitals.
She is presently employed by the Mercy Health Partners in Cincinnati, a region of Catholic Healthcare Partners Health System.
Previous experiences include progressive leadership roles including chief nursing officer, with responsibilities in Med-surg, Telemetry, ICU, OB, Psychiatry, ED, Cath labs, Surgery, Ambulatory Surgery Centers and Homecare. In her current role as the Regional Director of Patient Safety and Accreditation for a health system, she is responsible for accreditation and patient safety compliance for the system's 5 hospitals, homecare, and numerous ambulatory and longterm care sites.
Ms. Snyder is board certified in Nursing Administration (CNA) by the American Nurses Credentialing Center. She is also board certified as a Certified Healthcare Safety Professional (CHSP) at the master level through the Board of Hazard Control Management.
• 3/8/09: Dr. Rosie L. Stanfield; two children; four stepchildren; ten grandchildren and one great-granddaughter [from http://articles.baltimoresun.com/keyword/stanfield]
Comments:
• 12/8/09: She focused on data and how we use it, employee evaluations and competencies, weight documentation and the policy on fluctuation and notification, primary cource verification for NON-physician licensed staff (particularly system at license renewal time), disasters drills, med errors, and if ALL documents in record were signed, dated amd TIMED. She did not take as much of an educator role and her strong military background was very evident.
Worked at St. Francis Hospital in Blue Island, IL; HCA Mountain View Hospital in Las Vegas, NV; Provena Mercy Center in Aurora, IL; HCA Chicago Lakeshore Hospital; St. Joseph Hospital and Medical Center in Chicago; and Christ Hospital and Medical Center in Oak Lawn, IL.
Experienced in medical-surgical and behavioral health nursing
35 years of hospital experience as Staff Nurse, Nurse Manager, Director of Nursing and Chief Nursing Officer/Director of Clinical Services
Nursing diploma from Evangelical School of Nursing, Oak Lawn, IL,
Bachelor of Science Degree from St. Francis University in Joliet, IL
Master of Business Administration degree from Lewis University in Romeoville, IL.
Comments:
•
Rec:
•Let her talk
Recent Survey History: 7/2/09@FSH/PSQ, two follow up surveys at Tinley Park 2008
Sureys: Accreditation Manual for for Behavioral Health Care
Lives: Florida
Work/:
Previously: Regional Director of Clinical Support Services - Behavioral Health Services and a Consultant - Hospital Services, of Horizon Health Corporation, Lewisville ,Texas.
Troester has a Clinical Specialty in Child and Adolescent Psychiatric Nursing and is currently licensed as an Advanced Registered Nurse Practitioner in the State of Florida.
experience with various levels of care, including Inpatient, Partial, Residential, and Outpatient behavioral health services
has worked in Psychiatric and Addictions Programs, Developmental Disability Programs
Comments:
• 12/11/09: Very nice. Main focus is patient care. Welcomes questions and works with you to fix any problems before final report is submitted.
• 1/30/09: focused on Adolescents and Developmentally Disabled/Mentally Retarded
• Thorough, reads every page of each chart. Focuses on competency data, psychosocial assmts and the treatment plan. Asks if hosp has chosen between CDC and WHO and wants to see proof/documentation.
• Pet peeve: Medical issues not integrated into treatment plan
• She is a vegitarian
• Re: 1/18/08 - Ms. Troester was very helpful, spent the majority of her time on our behavioral health units. Spent a great deal of her time with the Treatment Teams, reviewing cases, the actual record etc... She seemed very interested in the actual course of treatment and what the team process was, how they involved the patients and their families.
Work: Dr. Adma is Medical Director at KVC Behavioral HealthCare, Kansas City, Kansas. He is also Medical Director at Sunflower Centers of Paola, Kansas.
Comments:
• He was focused on C&P information, medical staff by-laws, leadership, review of scripts (range orders, verbal orders, do not use), review of MSO policy and brief validation we followed them, and review of initial assessments upon admission to ensure we IMMEDIATELY assessed suicide risk and put plan in action. VERY easy to deal with and helpful. He took more of an educator role.
• Quiet, patient -Soft spoken and sometimes hard to hear -Focus: medications/med management -Cited NPSG2 @ critical lab
Surveys: x 2004, Comprehensive Accreditation Manual for Hospitals.
Lives: Naples, Florida
Ed: MD from Tulane University School of Medicine in New Orleans, Louisiana, and completed his internship and residency in Psychiatry at The Harbor-UCLA Medical Center in Torrence, California. Board certified in General Psychiatry, Addiction Psychiatry, and Forensic Psychiatry. Member of the American Medical Association, American Psychiatric Association, the American Academy of Psychiatry and Law, and the Academy for Organizational and Occupational Psychiatry
Work: Dr. Capiola most recently served as the Associate Medical Director of River Oaks Hospital in New Orleans, and was an attending psychiatrist for The Masters and Johnson Program for the treatment of Trauma, Compulsivity, and Eating Disorders. He served as the Medical Director for The Partial Hospitalization Programs at River Oaks and the Extended Care Program for Compulsive Behavior. He served as the chairman of three hospital committees, Pharmacy and Therapeutics, Medical Records, and Utilization Review, and was a member of the Medical Executive Committee. Dr. Capiola also served as Interim Assistant Coroner for Mental Health in Jefferson Parish, LA.
Other: special interests include the development of efficient systems within healthcare organizations, medical communications and the media, medical-legal issues, risk management, and psychiatric administration.
Comments:
He focused on Medical Staff and their issue and looked at staffing. He was reserved, direct, showed no indication of
positive or negative affect. However, at one point he became inappropriately testy with staff when they attempted to politely interrupt (a meeting with the medical staff) and let him know he was running behind for a meeting he requested that had 16+ people waiting.
Rec:
Be prepared for a focus on Medical Staff
Escorts when assigned should ask up front if he wants to be notified/reminded when he is running behind. In any event always have your people show up on time and warn them to be prepared to wait quietly/patiently. A failure to allow sufficient time for sessions may be a useful RFI mitigation factor later, so don't push without permission.
Work: Currently Clinical Professor of Psychiatry at the University of California, San Diego. Prior to joining TJC Dr. Flocks was a partner physician with Southern California Permanente Medical Group, Kaiser Permanente Medical Care Plan {TJC}
Ed/Train: Board Certified in Adult Psychiatry and is currently l icensd in California as an MD. He is also a Distinguished Life Fellow of the American Psychiatric Association {TJC}
Comments
3/24/10: As indicated by SPHCC advice a stickler for the hand hygiene between each patient on medication pass, He focused on Medical Staff and the OPPE and FPPE practices and meet with treatment teams and medical staff. Overall friendly and helpful.
3/12/10: Conducted tracer or survey activities in patient care, Performance Improvement, Contracts, Credentialing, Medical Staff, record of care, medication management, rights of individuals and NPSG. This is not our first visit from Dr. Flocks, he also surveyed our hospital in 2007, so there was familiarity between senior management and this surveyor. He does have a focus on moving performance improvement out of bar charts and graphs to statistically evaluated information, which he mentioned in 07 and fortunately he was able to find in this survey. Did provide a educational presentation on medical staff credentialing that was helpful to staff managing that process. Generally very willing to talk through findings and expectations. Was a bit pressured to work through what is now a 2 day survey (three day in 2007).
11/20/09: Friendly but very focused. A high emphasis on risk assessment; especially as related to suicide, both from an environmental and clinical aspect. Loves to teach and is very knowledgeable. A true statistician who loves data presentation in the form of graphics, charts, etc. as related to any area being discussed. Very focused on the credentialing process and legibility within the medical record. Believes it is disrespectful for someone to be late to a given meeting, etc.
May 2009: Would get focused on one issue and would discuss that topic the rest of the session. Wants to see statistical analysis.
Very engaging, friendly. He had a real focus on applying simple statistical tools to our data for the purpose of determining siginificance. We have lots of data/graphs/oryx benchmarked which did not satisfy him, he wanted the significance to us internally. We did not get a RFI but it did show up as a supplemental. Made some really good points on data analysis and medication reconcilliation.
Jay Flocks, MD, Psychiatrist and Team Leader. Collegial, friendly, definitely without a "gotcha" mentality. Fair, found problems we were aware of. If he saw evidence that we were actively working on an area, he did not deliberately try to amass 3+ occurrences; however, if they were there, he cited them. Insists that all sessions start/end on time. Has an “open computer” policy: will take corrections to findings until the end of the final day. Will not accept a “PO/IM” order without clarification; feels that this is asking a nurse to “prescribe” which is out of scope of the license. OK if it says “IM if PO refused or required”. Both surveyors (Hanson & Flocks) felt that a medication pass in a psychiatric hospital, where patients line up to receive a cup, is “direct patient contact” and thus requires handwashing between each medication ;pass. During discussion of CDC guidelines, they both independently stated that a nurse should not need to think about whether skin contact occurred; should just automatically wash between every patient.
Special Note: In the Leadership meeting Dr. Flocks will sometimes present a special diagram and ask leaders to describe something they have done in terms of the diagram's 5 pillars.
Deputy Director of Medical Operations, Headquarters, Air Force Inspection Agency
Master Inspector of clinical services, Aerospace Medicine and Occupational Medicine.
Certified in Psychiatry, Aerospace Medicine and Occupational Medicine
Comments:
•Re Sep 2009:
·Focused a fair amount on environmental issues, especially hanging hazards.
·Very serious about importance of med errors. Says Every year we “Kill” approximately 50,000 people with med errors… equivalent of an airplane cras each day.And thinks only about 50% are reported.Says there is a need to strive for zero errors like in the airline industry
·Dr. states the old meds work as well as the new expensive ones
·Acronyms – Dr. G. does not like them
·Nursing staff should lower threshold for legibility if you have to get someone else to interpret it is illegible. Constantly checking charts for:legibility, do not use abbreviations, all entries signed/dated/timed.
·A staff MD asked what the physicians could do to help decrease med errors.Dr. G. was impressed he asked.His answer was legibility.
·Dr. G. states he loves being a surveyor because things get fixed for the good.
·Dr. G. was concerned about infections to include “bed bugs” , mosquitos (spied larva eggs) in standing water and
·A stickler on not giving temp privileges unless all required documents are present
·.Very tuned in toward staff’s attitude toward patients.Became highly irritated when an RN insinuated a patient was complaining to get staff in trouble.
·Very focused on H&P’s.Anytime part of a PE was “deferred”, he wanted to know:why deferred, deferred until when, and what was the plan?Extremely biased toward this area, insisted that no body system go unchecked during a physical exam(Cited as a CMS CoP).Also checked timeliness.
·Many questions regarding competency/staffing.(Asked questions of nurses pulled to other units, nurses new to facility, psychiatrist why she is competent to treat physical complaints when there is a med clinic available)
• Re 7/29/08 Validation Survey: Dr. Geeze is a retired air force psychiatrist with a strictly military point of view. After retirement five years ago he went to work full time for TJC. He explained the validation survey requirements, asked me for my RFI's from the last triennial and my recently submitted PPR. He then just went on to "do his own thing." He never surveyed one RFI. He went to a unit, asked for a pajama bottom or sheet and proceeded to attempt to tie same onto any surface that would hold. He found they held on sink faucets and cited us for that. Then he pulled on the breakaway shower curtain rods, toilet paper holders, etc. Went to a chart and found some words unreadable. Looked for expired meds in the med room. That's it. Went to three more units, looked for illegible words, talked to one patient for no more than five minutes and checked for expired medications. I had my staff running to gather data to show that we had taken care of the RFI's but he never asked for anything. He did not like our suicide risk assessment because there were no ratings assigned to the risk factors that he wanted us to add up (even though this is contrary to current published thought on this issue, which of course no one mentioned). He asked to see a physician's credentialing file and then felt that global privileges "allow physicians to do whatever they want." He gave us a military credentialing profile which is so specific it lists every possible assessment/intervention a psychiatrist might everdo. This, I believe, would be a lawyer's godsend. We ended up with the requisite 4 RFI's, he told us "we are on the cusp of being a premier hospital" with really nothing to back that up.
• Prior to joining the Joint Commission Dr. Hart served in the U.S. Navy as Hospital Medical Director, Hospital Commanding Officer, and Director of Navy Medicine Research and Development. Dr. Hart’s latest position was Navy Medicine Inspector-General.
• Dr. Hart is board certified in Family Medicine and AeroSpace/Preventive Medicine and is currently licensed in Iowa. Dr. Hart also maintains certification as a Healthcare Executive and is a Fellow of the American College of Healthcare Executives.
Comments:
• Did not know psychiatry very well, was very focused on data, its presentation & analysis. Extremely rigid and apparently overmatched when asked to consider problems and responses differently from how he was accustomed to seeing them.
• Dr. Josef has been practicing psychiatry since she graduated and has worked in Dacca, Bangladesh, Phalombe, Malawi and Siteki, Swaziland from 1969-1971 before coming to the United States and working in a private practice part-time in Michigan from 1975-1980. In 1976, she became the Director of the Adult Inpatient Service at the Lafayette Clinic in Detroit, then became a consultant in psychiatry for the Psychiatric Center of Michigan Hospital, St. John’s Hospital and Southwest Detroit CMH Center before locating back to the Lafayette Clinic in 1988 where she was the President for the Medical Staff. She was a professor and interim Director of Geropsychiatry CRP at Wayne State University from 1991-1996 and a Director at the Walter P. Reuther Psychiatric Hospital from 1990-2006. She received both her Associate in Arts (Pre-Med) and Doctor of Medicine ‘Cum Laude’ degrees from the University of Santo Tomas in Manila, Philippines in 1958 and 1963.
Surveys: CMS Special Conditions for Psychiatric Hosptiatls (B Tags)
Lives: MI
Work:
• 2007: Medical Director, Macomb County Community Mental Health Services
• Had worked as a CEO of a large psychiatric hospital.
• Residency: Albert Einstein Med Center
• Article: Methylphenidate in the treatment of aggression in two patients with antisocial personality disorder ( AY Stringer and NC Josef)
Sureys: Accreditation Manual for Hospitals, Long Term, Critical Access Hospitals, Integrated Survey Process for Ambulatory Health, Home Care, Rehabilitation Hospitals, Long Term Care, and Behavioral Health.
Lives: Georgia
Work Hx:
private and public psychiatry in Thomasville, GA. Chief Clinical Officer for Summit County in Ohio. Medical Director at Mecklenburg County Mental Health in North Carolina. Psychiatry Residency Training Director and Director of Consultation- Liaison Services and co director of the Internal Medicine and Psychiatry training program at East Carolina University School of Medicine. Past faculty member of Harvard Medical School, the Medical College of Georgia, East Carolina University and the University of Pittsburgh’s School of Medicine and School of Public Health.
Ed/Train:
BS from Cornell University, MD from Tufts Medical School, Masters of Public Health from Harvard University.
Comments:
• 6/19/09: Lead Surveyor - he focused on national patient safety goals and credentialing
• May 2009: Very detail oriented particularly in the area of Environmental Risks within a Psychiatric facility. Steadfast in meeting each aspect of all standards.
• April 2009: Survey Leader - Worked to set a customer service based survey environment/culture. Took time to explain his reasoning on a subject, and as well, provided time for you too as well.
• Feb 2009: Tips: He's reasonable and you can convince him to see your side of things. His best advice (and I held him to this) was: "you only need to show me you meet the standard at a 'D' level, not an 'A+' level." He gave us lots of ideas on how to improve but didn't hold us to the A+ measure in the end.
• Dr. Katz served as team leader for the Indiana system in 2007
• Edward Katz, MD 3/9-3/12/main surveyor/tracers/med managemt-fair, took time to explain his reasoning and accepted our explanations
Beds - Total (Total number of beds in a facility, including those in non-Participating or non-licensed areas): 189 (as per hospital-data.com, 4/6/10)
She has been practicing medicine for more than 40 years. (as per OrganizedWisdom.com, 4/6/10).
Medical Education
Kordylewska attended medical school at University of St Andrews, Medical School , St Andrews, Scotland (as per OrganizedWisdom.com, 4/6/10)
St Andrews- ScotlandGraduated 1969 (as per Doctor.com, 4/6/10)
Comments:
• Jan 2010: Friendly, but somewhat reserved and soft spoken. Broad experience, from private practice to state forensic hospital. Thorough in her individual tracers. Interested in seeing if patient plan of care was updated when changes occurred in patient's condition or patient moved to another program/level of care. Typically satisfied with what she saw in our records. During individual tracers, she asked very specific questions aimed at addressing processes (e.g., - how are labs ordered, drawn, and results accounted for?, how do we use high risk medications and clozapine; how are medical staff involved in assessment of the environment (safety, suicide risks, razors, patient accountability; how we used Standing Orders). Strong focus on the role of the Medical Staff/MSEC in providing direction to the hospital and its PI program. Conscientious in reviewing credentialing and privileging files. Closely examined, and asked questions about, OPPE and FPPE processes.
Surveys: Comprehensive Accreditation Manual for Hospitals/trained in the Integrated Survey Process.
Lives in Virginia and South Carolina.
Ed: BS from Clemson University in Clemson, MD from the Medical University of South Carolina.
Past Work: Hospital Director and Medical Director at Southwestern Virginia Mental Health Institute in Marion, VA; Director of Forensic and Court Services at Eastern State Hospital in Williamsburg, VA; Commissioner for the Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services; and Hospital Director, Medical Director and Director of Forensic and Court Services of Central State Hospital in Petersburg, VA.
Other: Faculty appointment at the University of Virginia in Charlottesville. Life Fellow of the American Psychiatric Association, and affiliated with the Psychiatric Society of Virginia and the Southside Psychiatric Society.
Comments:
• Old school physician, full time surveyor who is getting older, but continues to have the ability to see the most significant issues and to be "on target". He is one of those old-timers who cuts through "fluff" with ease and diplomacy. (Believe that he was the commissioner in the state of Virginia for many years.) He is fair and fairly thorough. May start off rough/tough but usually eases up in the end. Very strong on medical staff, bylaws, rules/regs, privileging, if CEO participates in Med Exec Com, he liked the Indiana State Hosp Bylaws – looks carefully @ fire extinguishers in locked encasement, strong on competencies, often checks temp in med prep rooms, does med record reviews quickly, often asks about assessment of physical functioning status. May ask MDs about their role in pain assmt.
•Pet peeves: legibility, PRN meds orders lasting longer than 30 days but never used.
• Doesn't eat/like turkey or bottled drinks
Recs:
Just listen and no debates. Allow him to teach. Doesn't often give type 1's unless someone p---- him off.
• Education: Med School-Case Western Reserve Univ Sch Of Med, Res - Univ Hosp Of Cleveland, Psychiatry
Comments:
• Very thorough but friendly and collegial
• Re: 1/18/08 - He seemed more concerned about the history and physicals and emergency management information than he did with anything else. He only reviewed one treatment plan and didn't seem real concerned with a tracer taking him through the medical record. We did not learn from him that he was nervous or scared of our FMHS unit until after Ms. Stewart was here and announced the immediate threat. In fact, the morning review with Macklin and Troester was very positive and then 4 hours later they put us on notice that we were placed in Immediate Threat. When this was brought up to the survey team, they didn't answer why they were not upfront with us. It was very unusual and seemed suspect.
*(More GRH Info - acute care facility providing a full range of services to residents in Geauga, Ashtabula, Cuyahoga, Lake, Portage and Trumbull counties in Northeast Ohio. As a member of University Hospitals Health System, it offers care in more than 40 clinical specialties, including diagnostic imaging, emergency medicine, diabetes education, family practice medicine, nutrition counseling, sports medicine, behavioral health, and occupational health.),
Work: He is the former Medical Director of the Fulton County Department of Mental Health, Developmental Disabilities and Addictive Diseases and currently is the CEO/Chief Psychiatrist for Peachstate Psychiatric Services in Atlanta.
Other: Board certified in General Psychiatry and board eligible in Forensic Psychiatry. On faculty for the Osler Institute in Terre Haute, Indiana.
Comments:
You might obtain more insight by looking over his newsletter, facebook page or webblog
He seems fair, but may not always allow adequate opportunity for responding to his questions.
Does not miss anything. My second survey with him. Focus on NPSG and Pharmacy. Also is big into Forensics and competency for those that care for forensic patients. We only had three in the hospital and much time was spent on this subject. When things start going bad he can get even tougher.
Rec:
Be sure staff follow-through on any of his requests for additional info. If staff feel uncomfortable about an issue, they should make a point (perhaps later while he is walking to next activity) of POLITELY asking if he thought their answer to the matter in question 'was satisfactory or not'. If so, make a written note of this, but let it go, if not/uncertain, they should make their own request for time during 'Issue Resolution' to ensure complete answers/info has been given.
If you will allow him to he will teach and consult. When he does you need to listen.
• Dr. Race has 32 years experience in health care as a physician, consultant, psychiatric hospital medical director, hospital vice president of medical affairs, chief medical officer of a campus including medical, rehabilitation, and psychiatric hospitals, outpatient care center medical director and provider for public mental health centers, and most recently held the position as Medical Director of Behavioral Health for the Texas Department of State Health Services.
• He currently is active with the Hospital Division of the Texas Department of State Health Services.
• Dr. Race is Board Certified in Psychiatry and is a Distinguished Fellow of the American Psychiatric Association. He currently holds medical licenses in Texas and New Mexico.
Comments:
• 11/30/11: Friendly and easy going. Is very knowledgeable and likes to teach. Focused on credentialing issues and treatment plans.
• 8/13/09: Friendly, easy going but sharp. Keyed in on credentialing and contracted services. Very consultative in the survey process, listen and learn. Have coffee available upon arrival.
• 7/24/09: Consultative, likes to tell stories, sharp, puts you at ease but is paying very close attention
5/21/09: Focused a lot on the environment/Kind of "all over the place" - didn't do tracers the way we expected him to. Lots of emphasis on details sometimes at the expense of the big picture.
• 4/21/09: Focused on NPSG, Medical Staff Credentialing and Privileging, Leadership, Waived Testing, Medication Management / Be aware that Dr. Race may expect some documents for the Preliminary Planning Session that are not typically on the TJC suggested list. ( e.g., the Emergency Management Plan, EOC Management Plans, various policies). If he couldn’t find a document quickly, he assumed it wasn’t there. Dr. Race approached tracers in a manner different from what we expected in that he did not follow a system all the way through to the end. When something else caught his attention, he chased it down immediately. He was also noted to use his experience and practice in his own hospital as a baseline for investigating practices at our facility. First impressions carried a lot of weight with him. For example, if the first nurse he met didn’t know something he asked, he assumed all nurses lacked the knowledge. We found the best way to manage this was to get him what he asked for quickly, listen respectfully and answer his questions without over explaining. To his credit, he was quite willing to be consultative and we received useful information on topics related to National Patient Safety Goals.
• Very personable and reasonable, made staff feel at ease and seemed to understand State Hospital systems. Although he, too, made a finding that we were able to remove with a clarification - he found patients with pain reassessments not completed within our required span by selecting patients who had multiple medical problems so they left the unit for medical appointments after receiving a pain med.
*More info/feedback is needed on this surveyor. To add your input, click here or use our online form to add your input atwww.shccPSQ.com. Thank you.
TJC Bio (x )
Sureys: Accreditation Manual for Hospitals
Lives:
Work:
•
Comments:
• Re: 1/18/08- Ms. Stewart joined the survey process mid way and stated that she was there to review the performance of Macklin. She seemed rather abrasive at first but was very direct and firm in her responses. It seemed that the entire survey process was going okay with Macklin and Troester and then when she arrived, it went completely awry. She thought that we had not completed a sentinel event, assumed the Psychiatrist that we had that ultimately died from assault he endured in our FMHS unit, was a patient. When that was finally clarified that we were not in the wrong then they pulled apart the root cause we did after that event and cited us with Immediate Threat stating that Dr. Macklin felt threatened when he was on this same unit that our Psychiatrist was assaulted. In the root cause we did after the Psychiatrist was fatally injured, we identified several steps that we would do to improve safety one being the installation of camera equipment, another to move the water fountain, etc... They felt strongly that we needed to have guards, move our medication room, and to identify a way to handle our emergency alarm system. When she returned for the follow up, she seemed very helpful and although very direct in the way she communicated, she seemed genuinely pleased with the follow up measures we did to correct the immediate threat.
