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4.09.2019

University of Miami Hospital and Clinics Successfully Pass Latest Joint Commission Inspection

Nine inspectors from The Joint Commission showed up unannounced at UHealth Tower one Monday morning in December. Their primary goal was to ensure compliance with more than 5,000 standards that focus on patient, individual and organization functions essential to safe and high-quality care.

They also wanted to see first-hand the success of the merger of the three acute care hospitals and other facilities that made up the University of Miami Health System before October 2017. Did all three hospitals operating under one license, now known as University of Miami Hospital and Clinics, manage to combine and harmonize their culture, processes and policies, as promised?

As it turns out, yes.

After five days of Joint Commission scrutiny, the health system emerged with flagged findings representing 0.1 percent of the 5,365 compliance standards.

The Joint Commission returned subsequently within 45 days to check on the status. UHealth passed the entire review process.

“We successfully completed our Joint Commission inspection thanks to a wonderful team effort,” said Dipen J. Parekh, M.D., chief clinical officer for the University of Miami Health System and professor and chair of urology at the University of Miami Miller School of Medicine.

Continuous preparation and commitment to high quality care were essential.

“It was people working together like I’ve never seen before,” agreed David Sinclair, M.D., M.B.A., UHealth’s chief patient safety and quality officer. “I attribute our success to multidisciplinary collaboration and inter-departmental cooperation. Multiple teams had to demonstrate a commitment to better care and outcomes. Engagement from senior leadership was also an integral part of the success. I’m very proud of the recognition we received.”

A lot of ongoing work — some of it behind the scenes — was crucial to the success. A weekly newsletter to ensure compliance, and an alert system similar to the emergency alerts used for public emergencies, gave all relevant parties within UHealth quick notice the morning the inspectors showed up.

“We had to create the Emergency Notification Network from scratch, including a distribution list of the key individuals,” said Ruben de la Vega Jr., M.S.N., RN, director of Quality Management – Hospital Accreditation. “We also created a WhatsApp group for individuals to know what items were identified during the survey.”

Preparation for the inspection also included creation of two command centers, one for clinical and the other for environment of care, that could spring into action on a moment’s notice.

“Remember, there were nine surveyors. One might be looking at the building structure while another is looking at clinical components,” de la Vega said. “We wanted to make sure the resources were allocated appropriately and there was good communication between the two centers. It was a monumental task to gather 16 hospital-based sites that had never been together, including three acute care hospitals merging into one.”

The surveyors identified no immediate threats regarding patient safety during the December visit. “A lot of their findings were limited in scope and limited in terms of impact on patient safety,” de la Vega said.

The Joint Commission surveyors, including two physicians, were impressed with physician and staff cooperation and receptiveness.

“The surveyors were quite complimentary, particularly regarding the level of physician engagement,” Dr. Sinclair said. Rather than avoiding the inspectors, he noted, many physicians engaged them in conversations.

One of the surveyors commented that “this was one of the few surveys he has conducted where physicians sought him out, as opposed to him seeking them out,” de la Vega said. “The team lead surveyor from The Joint Commission was very complimentary on both visits about the seamless process. They saw a very harmonized, very collegial health system.”

It’s one thing to claim you’re a collaborative team; it’s another to dress the part.

“One of my strategies was to have everyone wear the same color as part of a dress code,” de la Vega said. Although he knew the inspectors would show up on a Monday for the five-day inspection, he didn’t know which Monday. So he had a plan. The first day staff could wear any color. However, on the second day, everyone would wear red.

“On Wednesday, we wore rust or maroon,” he said. “On Thursday, we wore purple. On Friday, the verdict day, everyone wore black or navy blue.”

The goal was to show teamwork and cohesion by everyone wearing the same color.

“It was intentional on our part, and it worked,” he said.

Some policies and protocols the surveyors discovered at UHealth could end up on their list of recommendations for other institutions.

“There were several surveyors who recommended our processes to their leading practice library, a compilation of their best practices across the county,” Dr. Sinclair said. “That stood out for me as a noteworthy accomplishment.”

The work doesn’t end now that The Joint Commission inspection is complete.

“My philosophy focuses on a constant state of readiness. We don’t lower our guard,” de la Vega said. “At any moment, we can have the Agency for Health Care Administration, the Centers for Medicare and Medicaid Services, or The Joint Commission knocking on our door.”

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