Our Quality
January 1, 2008
To our Patients, Families and Visitors:
Dunn Memorial Hospital is please to share with you the details of our March 2007 review by the Joint Commission. The Joint Commission is an independent body of medial reviewers that evaluates and accredits approximately 15,000 health care organizations in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. For more information on the Joint Commission we invite you to visit the website: www.jointcommission.org.
During every Joint Commission visit, the surveyors are given complete access to the hospital, staff. The review is based on the treatment and care provided to patients to ensure quality and safety. If a concern is noted by a surveyor an “RFI” (Required for Improvement) may be noted on the report. Dunn Memorial Hospital was happy to welcome the surveyors and open our hospital for their full review of our patient and safety processes. The hospital was notified immediately after the review, that accreditation would be granted for an add ional three (3) years. Dunn Memorial Hospital was reviewed according the Accreditation for Critical Access Hospitals of which there are greater than 200 standards. The following are a list of improvements noted by the Joint Commission:
Medication Management:
Medications are properly and safely stored between receipt of a medication by an individual health care provider and medication administration.
DMH Action Plan: Policy was developed regarding medication administration and disposition of medications that includes safe storage, safe handling, security and disposition of medications with return to the storage area.
Organizational Structure:
Timeliness of reporting: Measure, assess and take appropriate action to improve the timeliness of reporting, and the timeliness of receipt by a responsible, licensed caregiver of critical test results and values.
DMH Action Plan: Critical test report form has been developed that includes the times of ordering, resulting and physician notification of panic or critical test values.
Verbal and telephone orders: The critical access hospital complies with applicable law and regulation regarding the signing of verbal and telephonic orders.
DMH Action Plan: Re-education of nursing staff was conducted. A stamp was also placed on each order form to assist with documentation of date/time of order documentation.
Thank you for taking the time to review our report. Dunn Memorial Hospital values the information received from the Joint Commission to improve our processes; thereby, improving our patient care and patient outcomes. It is the goal of Dunn Memorial Hospital to provide quality healthcare with a commitment to excellence.
Sincerely,
Mike Cooper
CEO
Dunn Memorial Hospital