Phoebe Putney Memorial Hospital Director of Quality Management Michelle Coalson addresses the hospital’s board of directors Wednesday. (Staff Photo: Brad McEwen)
ALBANY — Phoebe Putney Memorial Hospital recently completed its first year in a new accreditation program with favorable results, according to information shared during h the hospital’s board of directors at its regular meeting Wednesday.
Michelle Coalson, director of quality control for Phoebe, told board members that after site visits in February by surveyors from accreditation body Det Norske Veritas (DNV) Heathcare, the hospital was on track to meet its goal of integrating ISO (International Organization for Standardization) 9001 quality disciplines by 2016.
According to Coalson the hospital has already received DNV’s findings and has submitted plans for corrective actions based on those findings. She said DNV is now reviewing Phoebe’s responses and that the hospital is currently in the process of implementing and monitoring their action plans.
“We just recently completed our 2014 survey, and after every annual survey DNV sends us back the report in 10 business days and then we have to create corrective action plans around all of the findings that we were cited for,” Coalson said. “Then we have 10 calendar days to return those corrective action plans to them so they can review them. So we have done that. Actually, we submitted our corrective action plans on Feb 14 so we are now in the process of implementing and monitoring those plans. We do have to submit evidence to DNV on how we are complying and how we have corrected some of the nonconformities that were identified.”
Doug Patten, the hospital’s chief medical officer, said the DNV surveys only identified four nonconformities, an improvement over the number of nonconformities found in 2013.
“There’s only four,” Patten said. “We went from, I think 13, down to four from our first survey to our second. When you talk about nonconformities that means you have a policy you’re not following or you have a practice that you don’t have a policy for and that creates a nonconformity.”
Patten gave a current example of one of the nonconformities found by the DNV surrounding the proper completion of paper documentation within the clinical record. Patten explained that the standard for documentation holds that all paperwork must be properly completed and that if any paperwork is not legible or signed and dated properly, that would constitute a nonconformity.
“One of the things that we struggle with in terms of paper documentation is making sure that every single entry into the clinical record is legible, that it’s signed by the person that put it in there, and it’s also dated and timed,” said Patten. “There’s requirements that have to be met for every single entry into the clinical record. When we do it electronically, it’s automatic, it’s done, but when we do that in the paper world it’s a little challenging. So when we’re not at 100 percent for that, that’s a non-conformity. That’s an example. So, we’ve submitted a corrective action plan to continue to try and improve legibility and improving compliance with signing, dating and timing on all those entries.”
Even with nonconformities being identified, hospital officials are pleased with the results and believe the DVN process will help the health care provider continue to improve as it works toward ISO 9001 quality certification.
“The DNV program is more consistent with our long-term commitment to patient safety and total quality,” said Joel Wernick the hospital’s President and CEO. “The ability to integrate ISO 9001 quality disciplines with our clinical and financial process is a major step forward.”