Physician-related findings from recent TJC survey require action

Five surveyors from The Joint Commission visited Saint Joseph Hospital for its triennial survey earlier this month and, while the results overall were exceptional, there were three physician findings that are considered high level and require action plans for correction.

• Unlabeled propofol syringes were discovered on the Anesthesia cart.

• There were multiple improperly completed or illegible patient consents.

• Surveyors witnessed a failure to properly mark a surgical site.

There were other moderate violations that also will be addressed concerning proper attire, unapproved abbreviations, incomplete H&Ps and several more.

“We will collaborate with the appropriate medical staff members to create action plans and audits,” said John Tynes, MD, Saint Joseph chief medical officer. “But it also should be noted there were extensive acknowledgments from the surveyors about the many best practices they saw, and in particular called out our medical staff Credentialing and Peer Review processes as exemplary.”

Kudos and our gratitude to Marshall Gottesfeld, MD, Credentials chair, and Adam Koszowski, MD, Peer Review chair, and their committees for exceptional work! Further, one surveyor stated our OPPE and FPPE processes were the best practice he has ever seen. Well done to the Medical Staff Services team!

Thank you in advance to the physicians who will be asked to help address the high-level findings listed above, as well as to all physicians for your ongoing commitment to continuous improvement and regulatory readiness.

Physicians with questions about the survey can contact Tynes for more information.