The Memorial Hospital (TMH) is above standards for patient care but needs to improve its "bricks and mortar," according to the Joint Conference on Accreditation of Hospital Organizations (JCAHO).
JCAHO surveyed TMH on Monday and Tuesday. TMH volunteers to be surveyed for accreditation by JCAHO. There were 568 standards surveyors reviewed, ranging in areas from organizational ethics to management and patient care.
TMH scored high in areas of communication between staff and all aspects of patient care. The lower scores came from building deficiencies. TMH received a preliminary score of 82 percent. Official, final results will be made public in 45 to 60 days.
"All of our direct patient care scores were excellent. Our areas identified for improvement are all fixable," TMH Community Relations Director Heather Houseworth said.
Life safety codes, such as fire alarm systems, electrical emergency wiring, credentials of non-employee personnel and fire drills, were deemed by JCAHO as needing work.
"This doesn't mean the hospital is unsafe," TMH Administrator Randy Phelps said.
TMH did receive a preliminary three-year conditional accreditation. Conditional means TMH must "address and resolve the deficiencies," according to Phelps. With some of the lower score areas, TMH will be able, before the final report is issued, to show immediate improvements.
"We have an opportunity before the final report comes out to provide the proper documentation for some of the opportunities for improvement they questioned," Houseworth said. "We are continually trying to improve it just can't happen overnight."
According to Houseworth, JCAHO has been under fire from the government for some of its policies, resulting in the upgrading of its standards. The surveyors, a physician and a nurse, told TMH the quality of care was excellent, but that there are areas to improve, Houseworth said.
"Since we are voluntarily participating, this is an education process on how we can continue to improve the quality of care at TMH," Houseworth said.
A JCAHO accreditation lasts for three years. TMH teamed with JCAHO for accreditation procedures in 1991. In 1991, TMH received a score of 51 percent; In 1994, an 88 percent; and in 1997, a 90 percent.
JCAHO scores facilities on a 1-5 scale. One, the highest score possible, recognizes "substantial compliance" while 5, the lowest score, is "non-compliance." If a hospital received a "1" in all categories, the overall percentage would be 100. These percentages are also compared to other facilities nationwide.