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Healthcare Professionals / Progress Notes / Quality/Risk Management / The Joint Commission will visit LGH this summer. Are we ready?

The Joint Commission will visit LGH this summer. Are we ready?

Dr. Charles H. Rodenberger, President of the LGH Medical and Dental Staff

Lancaster General Hospital’s next Joint Commission accreditation survey is expected this summer.

To prepare for that unannounced site visit, LG Health’s senior leadership invited The Joint Commission to conduct a mock survey, Tuesday, Jan. 27, to Friday, Jan. 30.

The mock survey – which is very similar to the actual accreditation survey -- will help identify patient safety risks, instances of regulatory noncompliance and opportunities for improving care processes.

A team of three physicians and one engineer will interact with care providers, observe and review care processes, interview patients, examine documentation within patient records and request group interviews to understand and assess key processes.

“The (mock) survey is an outstanding opportunity to identify gaps in our current care and to learn best practices from around the country, helping us to maintain our preeminent status in patient care,” Dr. Charles H. Rodenberger said.  “The outcome of the survey will – hopefully, and with your help -- solidify our public reputation for quality care.”

The survey will include:

  • Patient tracer activities, following the care experience from point of access/admission through discharge/departure from the ambulatory service. There will be heightened emphasis on patient handoffs and communication; suicide prevention (assessments and strategies); lab integration (specimen processes, POCT and flow of communication related to results); and patient flow (evaluation of processes, challenges and improvements).

  • Group interviews, most likely with Leadership, Data Management (Patient Safety, Quality and PI), Infection Control, Competence Assessment and Medical Staff Credentialing and Privileging

  • Facilities inspection of the physical plant and environment for safety and emergency preparedness, and reviewing environmental safeguards

“Please help the Joint Commission surveyors help us and help our patients by taking the time to answer their questions and assist them as needed,” Dr. Rodenberger said. “Let’s make this a most fruitful and rewarding experience.”

If you encounter the survey team, be friendly and only answer the question asked. LG Health will write and submit plans of correction for any issues TJC identifies. Physicians may be asked to share knowledge and expertise related to any identified issues or concerns.

The Accreditation & Regulatory Standards Department will coordinate the mock survey and provide additional information as it becomes available. Call ARS, 544-5825, with questions or concerns.


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