Lebanon — Mary Hitchcock Memorial Hospital employees have been busy in recent weeks as they work to address several dozen citations found by a hospital accrediting organization during a November visit.
In a phone interview this week, Dr. George Blike, Dartmouth-Hitchcock’s chief quality and value officer, described the commission’s findings as “well within our expectations.”
Given Mary Hitchcock’s size and complexity, Blike said 53 findings out of hundreds of possible infractions is proportional.
Though the seven surveyors found about twice as many issues during their four-day visit Nov. 7 to 10 as the Joint Commission’s surveyors found during their last visit three years ago, Blike said that hospitals around the country — which chose to participate in the commission’s voluntary accreditation process — are being held to higher standards than they have in the past.
Though the bulk of the Joint Commission’s recommendations for improvement were minor — such as refraining from propping open storage room doors, keeping corrugated cardboard out of clinical areas and ensuring that electrical panels do not have equipment in front of them — a few were more serious, including improvements that need to be made to further protect patients in the psychiatric unit from self-harm, to improve disinfection practices and improve certain record-keeping practices, such as time-stamping consent forms.
Blike also emphasized that the surveyors did not find any immediate threat to life issues that would have resulted in a visit from federal regulators and forced the hospital to implement “a lot of aggressive measures,” he said.
In this case, though the surveyors will be back for a revisit this month to see how the hospital has addressed the citations, the hospital was not required to restrict the services it provides, Blike said.
Even so, the findings were significant enough that D-H President Joanne Conroy devoted part of a recent entry in Joanne’s Journal, a regular message from Conroy, to the hospital’s effort to address them.
“The number of citations push the accountability to leadership ... and we need to ask ourselves if we are effectively managing and monitoring to the standards,” she wrote.
Some of these are standards the hospital is required to meet in order to continue to accept payments from the Centers for Medicare and Medicaid Services, Blike said, but the Joint Commission also requires that hospitals meet additional standards in order to remain accredited.
“We sign on to be being held to these standards because it’s a high bar,” he said.
This year’s review primarily focused on national efforts to reduce the risk of self-harm by patients and improve disinfection, he said.
To reduce the risk of self-harm in the near term, D-H has staff “continually monitoring” the psychiatric unit, Blike said.
To further reduce the risk of self-harm in the long term, the hospital will be making alterations to the unit, including installing solid roofs in patient rooms and replacing door hinges, he said.
One of the reasons for the delay in making the required changes to the unit include a difficulty in obtaining the hinges and other necessary materials from manufacturers because they are in demand from hospitals around the country, Blike said.
To bring the hospital’s disinfection process into compliance, staff need to begin the cleaning process right after an instrument has been used, similar to the way that an individual might wash a dish before putting it in the dishwasher to prevent food from clinging to it, Blike said.
Though the hospital’s staff were well on their way to making these changes before the surveyors’ visit, he said, they have since been retrained in order to be prepared for the revisit by the Joint Commission this month.
“It’s having to go through an environment and apply a new set of standards on how to have a facility be just safer,” he said.
Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.