Lawrence General Shines in Joint Commission Survey

November 12, 2019

"One of the best surveys of the year!"

That’s a comment we heard from one of the surveyors from The Joint Commission after spending four days in late September inspecting Lawrence General Hospital and appraising our place among other hospitals in the country. As part of the triennial Joint Commission Survey, the surveyors visited numerous Lawrence General departments and off-site locations to evaluate the environment of care, patient care processes, policies, practices, and to identify and document areas of non-compliance with Joint Commission standards and CMS Conditions of Participation.

The surveyors also completed a number of “system” tracers that included leadership , environment of care/emergency management, medication management, infection control, staff competency, quality data management, and medical staff credentialing and privileging.

How did we do?

The Joint Commission Survey reinforces so much of what we already know – Lawrence General is home to a world-class group of passionate professionals, dedicated to the health of our community. We also know that the exceptional skill and dedication of mission-driven individuals across all departments leads to organizational excellence. The positive survey is more than a valuable snapshot in time, it’s testament to the power of people working together for something bigger than themselves.

The entire survey team was “extremely impressed” with the Leadership Tracer Session; our focus on quality improvement, commitment to the community for health care and other issues, and the close working relationship with the Greater Lawrence Family Health Center.

Joan Iacono, the Lead Surveyor, commented, “everywhere I go there’s evidence of teamwork, good communication across departments and with physicians.”

Digging Deeper

As with any quality survey, we want and expect surveyors to closely scrutinize, test us and find areas where we can improve. While the overall survey results were very positive, The Joint Commission did leave us with some findings and action steps for improvement. In presenting the findings of the survey, The Joint Commission uses, what is called a SAFER Matrix (Survey Analysis for Evaluating Risk), to score organizations on standards compliance. A copy of our SAFER Matrix and more information on survey findings is posted on the Employee HUB (search “Joint Commission”). Essentially, the SAFER Matrix is a prioritized work list. Surveyors found 27 examples of standard noncompliance compared to the national average of more than 35. The majority of the findings were in the lowest risk quadrant of the matrix (a good thing) and many were corrected before the surveyors left. We have 60 days to address the rest. In fact, one surveyor mentioned that under the previous scoring system the findings in the yellow, or “low harm/limited scope “quadrant of the matrix would not have been findings at all. In layman’s terms we’d be given an “A”!

For those four, somewhat hectic days in late September, the Lawrence General team showed the surveyors that our high level of professionalism, dedication, and top-quality care are hallmarks of our hospital every day, and across all departments. A point reinforced by so much of the surveyor feedback.

“It is very evident that your clinical team are highly engaged, and that performance improvement is woven through your culture,” commented lead surveyor, Iacono. “I am so proud of your employees. This is the best survey I’ve done all year.”

Regardless of whether surveyors are on site, our goal is always to behave as if they are. Adherence to the Joint Commission standards is the right thing for patient care. And as we strive for high reliability and organizational excellence – preparedness, practice, professional development, training and consistency always pay off in better quality for our patients. Congratulations and thank you for your incredible engagement while the surveyors were here, and for your ongoing compassionate care of our patients every day.