On Oct. 11, Nebraska Medicine, including the Department of Psychiatry, earned Behavioral Health Care Accreditation from the Joint Commission.
On Aug. 14, members of the Joint Commission visited the Department of Psychiatry, and a site visitor conducted a detailed review of five cases encompassing the Intensive Outpatient Program and Poynter Hall. In addition, the visitor interviewed two patients, walked through clinical spaces, met staff members, asked hundreds of questions, looked at our outcomes (SDS) data, and reviewed our plans for suicide screening and risk assessment.
“The reviewer was impressed with our care, teamwork, documentation, and focus on quality improvement,” said Dr. David Cates, Vice-Chair for Clinical Operations with the Department of Psychiatry.
For psychiatry, there were three findings: nutrition screen needs to include a dental assessment; when providers transfer care, they must create a formal transfer summary; and every new patient evaluation must include a cultural assessment. Action plans for addressing these findings were submitted to the Joint Commission.
“My thanks for everyone’s contributions to this team effort,” said Dr. Cates. “This accreditation is, in part, a result of the work everyone did in the past year screening for pain, documenting short and long term goals, and screening for exploitation. Current efforts by our staff to screen for nutritional status and cultural preferences, as well as completing discharge/transfer summaries as needed, position us for success in our next survey.”
In all, seven surveyors from The Joint Commission visited the Nebraska Medical Center and Nebraska Medicine ambulatory clinics as part of a routine accreditation site survey that occurs every three years. The unannounced survey took place from Aug. 12 to 16 and ensures compliance with the Center for Medicare and Medicaid (CMS) Conditions of Participation, a requirement to participate in Medicare and Medicaid programs.
“Overall, the survey went well,” said Dr. Harris Frankel, Nebraska Medicine’s Chief Medical Officer. “We should not lose sight of the fact that we partner with The Joint Commission to identify opportunities for improvement in patient quality and safety. The surveyors informed us that the number of findings, in part, tends to be proportional to the number of surveyor days, the size of an organization, and the complexity and footprint of the organization. We have some work to do going forward, and our teams are already engaged in planning that work.”
The joint commission will return for another visit in 2022.