July 31, 2012

Message from Deputy Vice Chancellor Pinson about the Joint Commission Survey

Dear Colleagues,

Together with Vice Chancellor Jeff Balser and all of our Medical Center leadership team, I want to express my sincere appreciation to each of you-- our talented and dedicated nurses, faculty, staff and administrators-- for the successful completion of the Joint Commission's survey of our hospitals and clinics. Your performance last week while undergoing one of the most rigorous surveys in recent years was truly remarkable. I know many of you have worked diligently for years to help bring our health system to its current status and the intensity of your efforts during the past few months increased further during the Joint Commission’s visit last week. We were particularly proud of the first class professionalism exhibited from every corner of our Medical Center.

Each of you was integral to our success during the Joint Commission's visit. Let me share some of the observations we heard from our survey team during the week:

• All surveyors consistently noted the engagement, professionalism, and passion of faculty and staff in the work of patient care and the overall mission of Vanderbilt Medical Center. There was never a question about the focus on our patients and their families, and this was reinforced with each interview when doctors and nurses talked with commitment and compassion about those in their care. They particularity noted the engagement of physician leaders who participated actively in the survey as part of the units where they care for patients: Dr. Ian Jones, Dr. Stephan Russ, Dr. Howard Jones, Dr. Bennett Spetalnick, Dr. Seth Karp and Dr. Jamie Dwyer were among those partnering with nurse leaders in the clinical tracers. The surveyors noted, that in some organizations, the physicians scatter and you wouldn’t know there even was a medical staff!
• They remarked on the vibrancy and energy of the Medical Center.
• The expanded role of pharmacists in the clinical team was noted as a best practice.
• There were no findings and only praise for patient care and quality of care. This included the Emergency Department, the Perioperative Area, Intensive Care Units and Inpatient Units, Dialysis Unit, and Labor and Delivery/OB in the VUH.
• There was praise for the Children’s Hospital: its staff, the quality of care, and the child/family friendly environment. There were no findings. Families were interviewed and offered consistent praise for the care of their children and of their families.
• The surveyors were amazed at the size and scope of our ambulatory environments and the methods they saw for medication reconciliation, end of visit summary, and patient identification.
• The surveyors witnessed Universal Protocols and Timeouts in all areas where procedures were performed. They observed that they were disciplined and flawless, noting in particular the white boards in the ORs to identify each component of the time out as it is performed.
• They were impressed by the completeness and attention to Hand Overs and the 100% compliance to hand hygiene that they witnessed throughout the Medical Center.
• Our system tracers for medication management, use of data and comprehensive system for improvement, infection prevention and control, emergency preparedness and medical records were identified as best in class.
• The surveyors noted that members of our leadership that were interviewed were “inspiring” in their energy and commitment to be the best possible. They noted the collaboration and coordination across each part of the Medical Center.
• Medical Staff and Credentialing had no findings, and surveyors were complimentary of our Peer Review process and the involvement of the departmental chairs.
• Policies and document review all went well with no findings. They were impressed by our informed consent and other documents written in understandable language and the involvement of our Family Advisory Committees to develop them.
• The cleanliness of our kitchens and work of Nutrition Services received positive comment.
• The transformation of our Psychiatric Hospital was noted by a surveyor that had previous experience surveying Vanderbilt. She complimented the investment and the results of that investment for patients, families, and staff.
• Each surveyor noted in their exit interview that if any family member or loved one was ill or injured they would take them to Vanderbilt.
• Repeatedly each day our surveyors expressed their gratitude for your hospitality and professionalism. Their doing so speaks highly of your expertise and grace under pressure.

As always, the outside review provided a few findings that we will successfully address in short order.

• They recommended that we publish more of the outstanding work that was highlighted in each of the sessions.
• We have some things to work on: Observations included a need for more timed entries when reviewing paper records; pre-labeling syringes and containers in advance of pouring/filling with medications and solutions; timely reassessment for effectiveness of pain management strategies; and one observation of labeling a blood specimen without redundant patient identifiers. They also noted a greater need for consistency when logging refrigerator temperatures in some of our clinics.
• We have the opportunity to focus on our Life Safety and Environment of Care, including preventive maintenance, inventorying, testing and monitoring devices and alarm/alert panels, securing all fire penetrations, training and competency verification of staff.

The many months of thoughtful preparation that went into this survey, and its successful outcome, offer further testament to your dedication and commitment to providing our patients the very highest quality of care and your dedication to Vanderbilt.


C. Wright Pinson, MBA, M.D.
Deputy Vice Chancellor for Health Affairs
CEO of the Vanderbilt Health System