From Fred Beyer, M.D., President, Medical & Dental Staff; Deb Riley, M.D., Patient Safety Officer; and Mike Ripchinski, M.D., Chief Clinical Officer
 
Thank you for your help with a very successful survey with The Joint Commission. 
 
We appreciate your efforts to deliver outstanding clinical care supplemented by strong infection control practices, clinical documentation, and excellent time-outs in the procedural areas and operating rooms.
 
We are proud to say that we had no deficiencies in our OPPE / FPPE process, and the surveyor commented on how our team was thorough, complete and prepared for the review. Thank you for your efforts in this work!
 
Regarding the Medical Staff, we do have a few findings to address as below. The Department Chairs and Chiefs will discuss action plans with you.

  • Immediate Use Steam Sterilization (IUSS or Flash sterilization) may not be used for provider convenience.

  • Remove duplicate narcotic orders (e.g. Dilaudid 2mg AND 4mg for moderate pain and Fentanyl for pain OR sedation).

  • Interim H&P not completed prior to operation/procedure

  • Lack of brief or complete op note following a procedure and before transfer to next unit of care

  • Procedural consents were missing the “time of signatures”

Thank you for your dedication and commitment to our patients!

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