ST. FRANCIS SCHEDULED FOR ACCREDITATION VISIT

St. Francis Medical Center is gearing up for an accreditation visit this week from the Joint Commission on Accreditation of Healthcare Organizations.

"Hopefully, you have three years between visits, so that whole time you're working on policies and procedures to make sure they're up to date," said Marcia Southard-Ritter, vice president of patient care at the hospital. "At the last minute you always go back and make sure you've crossed all the t's and dotted all the i's."

The JCAHO survey team is scheduled to be in the hospital Wednesday through Friday.

After its last survey in 1993, St. Francis received full accreditation with commendations, Southard-Ritter said.

Alice Brown, media manager for the commission, said about 90 percent of the hospitals accredited by the commission usually get some kind of recommendation for improvement during the survey.

"They do have the opportunity to make the improvement and demonstrate to us they've made the improvement," she said.

JCAHO looks at how hospitals measure up to about 500 patient-care standards on everything from safety measures for fires or other disasters to patient rights and post-operative infection rates, Brown said.

"They're very concerned about the environment for the patient and our responses to things like fires, chemical spills, even earthquakes," Southard-Ritter said.

"We've been working with our staff on things like, what would you do if you have various disasters in the hospital? -- How staff would respond to it, or even how visitors would respond to it. It's really been like when you take final exams and you go back and look at everything you've done during the year."

Survey team members will review patient records, staff licensing, written policies and procedures.

"We also look at not only the care of the patients, but things like human resources, leadership of the organization and management of the organization," she said. "We really cover the organization as a whole. We're looking at whether or not the hospital has the right system in place to ensure a good outcome for the patient."

The survey team will also interview administrators, physicians, care-givers and patients to see how those policies and procedures are being carried out to ensure quality care.

"It's not necessarily top-level executive people we'll be talking to," Brown said. "We go out into all the units. We interview nurses. We interview dietitians. We interview respiratory therapists. We want to make sure the people delivering the care understand the policies and are implementing the policies."

Patients will be asked if they've been kept up to date on their treatment and if they've received information about continuing treatment, if needed, after their discharge from the facility, she said.

Southard-Ritter said the hospital expects more than 300 people to be interviewed by the five-member survey team.

During this survey, St. Francis staff will see team members taking a different approach, Southard-Ritter said. "They used to be very structured and departmentalized," Southard-Ritter said. "They've changed it in the last two years to be a very integrated survey. They're interested in the outcomes of care of the patients and how other departments interrelate in providing that care."

Since the hospital has implemented patient-focused care, that's an approach staff members are comfortable with, she said.

JCAOH accredits 5,300 hospitals plus approximately 9,000 nursing homes, mental-health centers and home care agencies, Brown said.