Going for gold has resulted in a first for a hospital in Jackson, Tennessee. Regional Hospital of Jackson has earned The Joint Commission’s Gold Seal of Approval for both its Joint – Knee Replacement and Joint – Hip Replacement programs. The award is the culmination of an intense three-year process that reflects Regional’s dedication to meeting The Joint Commission’s national standards for health care quality and safety in these two areas of care. The “Gold Seal of Approval” is an internationally recognized symbol of quality that indicates an organization’s commitment to high quality patient care and its willingness to be measured against the highest and most rigorous standards of performance.
Regional Hospital established an orthopedic unit in 2010 after physicians, John Masterson, MD, and Kelly Pucek, MD, requested a dedicated area for total joint replacement surgery. Soon after the program launch, Regional Hospital decided to pursue the Gold Seal Approval certification for the programs. The process started in 2011 with reviewing the Commission’s Disease Specific Care requirements and consulting with other Community Health System facilities that had received the award.
“There are numerous standards you have to meet that can be interpreted in different ways. It really came down to interpretation of the standards,” said Lisa Wall, RN, Clinical Director of Orthopedic and Total Joint Center. “Anytime The Joint Commission comes in you are nervous because you want everything to be like it is supposed to be and they look at so many processes. Although we felt we were on the right path, you are never really sure you are until the examiners get here.”
Wall felt good about the process and its outcome but knew that there would be some things that would come to light that needed improvement. “That is what is great about pursuing this certification,” she said. “You really get to look for things you can improve on, which means better care for patients. It also starts a focused pattern of continuous evaluation of the programs and striving to always improve.”
The process started in 2011 when Regional began collecting data on patients who underwent total hip replacement surgery or total knee replacement. “We collected 24 months’ worth of data in preparation for the certification process,” said Wall. “We looked at that data from all aspects of the program and identified four areas we felt we could improve. We then collected data focusing on these four areas of improvement.
Not only were the measures we selected important but also the process of formulating and implementing a plan for improvement was equally important. “One area that we reviewed was blood transfusions rates which can impact infection rates. By November 2013 we had decreased the transfusion rate by 60 percent. We then had to make sure we knew how to sustain that improvement, so we continue to track this measure.”
Physicians were also a big part of the entire process both throughout the preparation stage and the survey. Masterson was a strong advocate for pursuing Gold Seal of Approval accreditation. “We know what it means to have a program go through this level of scrutiny. It is an arduous process but one that really causes us all to be better at what we do and how we do it which results in providing a higher level of quality care to patients,” said Masterson, an orthopedic surgeon with Sports Orthopedic and Spine Clinic in Jackson. “The whole process is multi-disciplinary and it takes all parts being on board to make things better and safer for the patient.”
Once the hospital felt it was ready, it submitted its application to The Joint Commission in January 2014. The survey took six months to get scheduled and on July 18, 2014, Regional Hospital of Jackson underwent its rigorous on-site review. A representative from the Joint Commission evaluated the hospital for compliance with standards of care specific to the needs of patients and families, including infection prevention and control, leadership and medication management. The Joint Commission’s Disease-Specific Care Certification Program is designed to evaluate clinical programs across the continuum of care. Certifications requirements address three core areas: compliance with consensus-based national standards; effective use of evidence-based clinical practice guidelines to manage and optimize care; and an organized approach to performance measurement and improvement activities.
“The surveyor spent a day looking at the programs from the moment when a patient comes in the door to the time they are discharged to outpatient therapy, a skilled nursing facility or rehabilitation facility or to home with home health. They looked at closed and open records, interviewed physicians and talked to a patient on the unit – all to assess our compliance with the standard” said Wall. “All processes were reviewed and evaluated from the pre-operative process, intraoperative standardization, post-operative care and discharge plans. They looked at Human Resource files on employees, physician credentials and the continuing education we offered our employees on total joints.”
At the end of the process, Regional Hospital of Jackson’s hard work and commitment to excellence had paid off. “The surveyor said we had best practices in several areas which meant they found nothing we needed to change in those areas. Pre-admission practices and pain control were two of the areas highlighted and there were no negative findings on our total hip program regarding the way we care for these patients,” said Wall. “He only had one suggestion on equipment use for total knee replacement patients. From everything we are hearing from other hospitals it is unusual to only have one suggestion for improvement for an initial survey. Our surveyor commented that this was one of the most mature programs he had visited. ”
While the hospital got a glowing report and has achieved the Gold Seal of Approval from The Joint Commission for its Joint Replacement- Knee and Joint Replacement- Hip programs, it does not mean they will be resting on their laurels. The Gold Seal of Approval credentialing is an on-going process that requires recertification every two years. “It is a constant process of identifying areas to improve in and working to implement those improvements,” said Wall. “Of the original four measures we started evaluating initially, we will drop two and replace them with two new ones while we continue to monitor the two original measures. It is basically a process of constant improvement in all areas and is a great way to make sure we are staying on top of things and giving our patients the highest quality of care possible.”
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