Accreditation report: Vail’s hospital needs improvements
VAIL Vail Valley Medical Center’s president is blaming sloppy record-keeping for the warning the hospital received on a recent accreditation report. The hospital received “conditional accreditation” from the Joint Commission on Accreditation of Healthcare Organizations. Charlene Hill, spokeswoman for the commission, said patients should keep in mind that their hospital is still accredited, though it needs to make some improvements to stay that way. Medical center staff is taking the report seriously, said Greg Repetti, the hospital’s president and chief executive officer.Overall, the hospital did well on the voluntary survey, receiving only five citations. Hospitals are allowed up to 11 citations before dropping to conditional accreditation. But what got the medical center in trouble immediately was failing to have record of a single employee’s credentials in that employee’s human resources file. That automatically made the hospital’s accreditation conditional.”We did very well,” Repetti said. “Now, we found a lot of things we need to improve in the process, and that’s the notion of why we do this. Otherwise, we wouldn’t bring these folks the first place.”Changes under wayThe commission also asked the medical center to make improvements in the home-care, hospice and home-health programs, which underwent evaluation in August at the same time as the hospital. All four evaluations noted similar problems.”A lot of them are documentation issues, and they’re issues, frankly, that we need to fix,” Repetti said. In the case of the home-care program, for example, the commission wants the medical center doctors to be more specific when they order home care for a patient. Since August, physicians have been instructed to change their documentation process to meet the commission’s standards, Repetti said. Linda Brophy, the medical center’s clinical nursing officer, agreed that communication and record-keeping are the two areas the staff most needs to improve. Already, the hospital is making improvements, she said. The hospital just spent $10 million installing a new electronic record-keeping system, which will make it easier for doctors to keep track of a patient’s medical records. Repetti gave an example: If a technician has a question on a patient’s X-ray, that technician would call up the patient’s doctor for an answer. Using the electronic record-keeping system, the doctor would be able to access the patient’s medical records, even from home. The commission evaluates hospitals on about 250 different standards, which change every year. It’s not unusual for a hospital to miss the mark on a least a few of those standards, Hill said. “What’s important for the community to understand is the fact that the hospital was in compliance, and they are making the changes they need to be in compliance,” she said. Vail’s challengesAll of the hospitals in neighboring counties – Valley View Hospital in Glenwood Springs, St. Anthony’s Hospital in Frisco and Aspen Valley Hospital – participate in the accreditation program. All three are fully accredited, but they don’t really compare to Vail Valley Medical Center, Repetti said. St. Anthony’s and Aspen Valley are smaller. And while Valley View is larger, the hospital doesn’t attract the “destination” patients the Vail Valley Medical Center gets because of the well-known orthopedic surgeons who practice there. Plus, the medical center is affiliated with the Shaw Regional Cancer Center – the only cancer center in the central Colorado mountains – which treats patients from a seven surrounding counties. Since Repetti came to the hospital about a year and a half ago, the number of patients the hospital treats has gone up almost 9 percent. Keeping up with the growing demand is a challenge, he said. Staying on top of the changing standards of the Joint Commission is another challenge, he said. Hospital staff conducts internal surveys every month to make sure it is meeting the commission’s standards. The hospital also has a team that works to ensure patient safety and that the hospital building and equipment are in good working order. “I want to be the best at what we do,” Repetti said. “If we can’t do it first-rate, then we shouldn’t do it here.”
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