June 14, 2018

One-day follow-up Joint Commission survey to take place between June 18 and July 2

The week of May 14, VUMC completed another successful Joint Commission (TJC) survey. The five-day unannounced survey consisted of thirteen surveyors. TJC is an independent, not-for-profit organization that accredits and certifies more than 20,500 health care organizations and programs in the United States.

TJC visits accredited health care organizations a minimum of once every three years to evaluate compliance with health care standards ranging from facility space and structural drawings to all aspects of a patients care continuum. TJC surveyors are doctors, nurses, hospital administrators, laboratory medical technologists and other health care professionals.

As surveyors review a patient’s experience in a health care organization, they talk to the doctors, nurses and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care and often speak to the patients themselves.

During the week, more than 200 VUMC staff were actively involved in survey activities. Involvement included service in the command center, as an escort or SWAT team member or being interviewed by a surveyor. Surveyors visited more than 100 areas both on campus and at Vanderbilt Health’s satellite areas throughout Nashville and the surrounding counties.

Although VUMC won’t receive the final accreditation document for a few weeks, the surveyors spoke with Medical Center leadership before they left and were highly complimentary of our staff’s commitment to providing great patient care.  Specifically, the survey team stated that if they had a sick family member, they would definitely bring them to VUMC.

During these five days the surveyors applauded our staff on numerous occasions:  

  • They paid particular attention to the unit performance boards across the Medical Center 
  • Highlighted excellent hand hygiene 
  • Noted clear evidence of assessment of fall risks and active prevention implementation
  • Complimented the leadership's timely execution of corrective actions onsite
  • Praised nursing staff on their ability to navigate the newly implemented eStar 
  • Noted that they survey a lot of locations, and that the staff's involvement, compassion and drive shown here is remarkable

TJC will conduct a follow-up visit to review a few opportunities for improvement around suicidal ideation assessments for incoming patients, physical space modifications for patients across VUMC with behavioral health diagnoses and reprocessing of sterile instruments. We anticipate TJC’s return between June 18 and July 2.  The survey team will consist of two to three surveyors and will last one day. VUMC will initiate the same Orange Alert protocol and open the command center for continuity of efforts with the review.

Please direct any questions related to the upcoming survey or other relevant areas of interest to lauren.terzo@vumc.org.