Naval Hospital Bremerton receives Accreditation from Joint Commission/Med IG

BREMERTON, Wash. (NNS) -- Naval Hospital Bremerton and its branch health clinics recently underwent a successful Joint Commission and Medical Inspection General accreditation survey and inspection process May 13-16.

"The Joint Commission Survey and Med IG inspection are in the bag. Both were tremendous evolutions and both were highly successful," Capt. Christopher Culp, NHB Commanding Officer addressed to all-hands, noting that the Joint Commission surveyors found no significant problems with such major areas as leadership, credentialing, emergency management, and provision of high quality care.

"They gave us a few areas to "tweak" but were extremely complementary of our care. We are reaccredited for another three year period. The Med IG was a best in class survey. The entire team felt that this was a top tier command and that the IG program managers all were highly professional and accomplished. They also took away a good number of 'best practices,'" shared Culp, adding that over 50 staff members were specifically singled out for their expertise.

According to Carol M. Butcher, Quality Management Department Joint Commission, Process Improvement Coordinator, one such 'best practice' noted by the Joint Commission surveyors was NHB's use of the MaxAir powered air purifying respirators (PAPRs) that optimizes respiratory protection.

"Before the 2009 H1N1 worldwide pandemic ended we, like every other hospital in the country, exhausted our respiratory supplies recommended to protect staff against infection. While some civilian facilities rationalized providing lower level respiratory protection, we sought to provide our staff with sustainable protection that would meet or exceed the recommendations of the Centers for Disease Control (CDC). We found that protection in the MaxAir powered air purifying respirators (PAPRs)," explained Tom Shirk, RN, BSN, CIC, Infection Prevention Coordinator, attesting that the MaxAirs not only provide the highest level of respiratory protection available, but they also protect completely against droplets from patients who are actively coughing and sneezing.

"Additionally, the commonly used disposable dense paper respirators quickly become uncomfortable to wear for any extended period of time. The MaxAirs provide a continuous flow of 100 percent filtered cool air to the wearer and can be worn for hours at a time," Shirk said.

The entire purpose of the survey and inspection was to evaluate the compliance of Naval Hospital Bremerton and branch health clinics at Naval Base Kitsap Bangor, Naval Station Everett and Puget Sound Naval Shipyard with nationally established Joint Commission and Navy standards. The results then determine whether, and the conditions under which, accreditation should be awarded to Naval Hospital Bremerton. By continuing to be an accredited organization, NHB enhances community confidence, stimulates the organization's quality improvement efforts, aids in professional staff recruitment, provides a report card for the public, offers an objective evaluation of the organization's performance, and provides a staff education tool.

"The inspectors were really impressed. They even remarked on how open and actively engaging with them our staff were," shared Butcher.

Mark G. Pelletier, Chief Operating Officer, Division of Accreditation and Certification Operations, passed along to Capt. Culp that "the Joint Commission would like to thank your organization for participating in the accreditation process. This process is designed to help your organization continuously provide safe, high-quality care, treatment and services by identifying opportunities for improvement in your processes and helping you follow through on and implement these improvements. We encourage you to use the accreditation process as a continuous standards compliance and operational improvement tool."

There is a difference between the Joint Commission and Medical IG survey teams, although their focus can and does overlap at times.

The Joint Commission Survey takes place every three years and is a hospital accreditation carried out by a civilian organization based on demonstrated high standards of patient safety and quality. Joint Commission standards deal with organizational quality of care issues and the safety of the environment in which care is provided. The surveyors evaluated specific NHB's compliance with established standards and identified strengths and weaknesses. The overall goal was not only to find problems, but also to provide education and consultation so health care organizations could improve.

The Medical Inspector General (Med IG) inspection also take place approximately every three years to assess a command's effectiveness, efficiency, readiness, capability, and quality of healthcare services in accordance with Secretary of the Navy, Office of the Chief of Naval Operations and the Navy's Bureau of Medicine and Surgery (BUMED) directives and instructions. Med IG also assesses interoperability, integration and collaboration with Department of Defense, other federal government, and civilian organizations.

An effective educational tool for staff members that has been used in the past is the command 'Focusing On Safety Staff Handbook.' The pocketsize handbooks have been specifically created to have personnel take it upon themselves to educate, communicate and participate in making NHB a safer place for staff and patients. The handbooks were then part of National Patient Safety Week Kick-off in March. The overlapping purpose of the Safety Week was to promote specific improvements in patient safety, heighten awareness on a wide range of patient-related safety topics and focus on problem areas in health care safety and how to solve them.

NHB's Chief Petty Officer Mess, with assistance from Education and Training department, conducted several directorate-wide Jeopardy contests that were specifically designed to tests panel members on the knowledge of the patient safety handbooks.

"Our Sailors carried the day. The handbooks are great study aids. I noticed our Sailors in the wards and clinics were refreshing their knowledge with them and the Jeopardy contests were a fun way to share that knowledge," said Command Master Chief Douglas George.

Rear Adm. C. Forrest Faison III, M.D., Commander, Navy Medicine West, and Commander, Naval Medical Center San Diego sent his compliments to Capt. Culp for a job well-done, "Congratulations to you and your team on an outstanding inspection and, more importantly, validation and affirmation of the truly outstanding job you and your team are doing caring for others and supporting the fleet. Well done!"

The Joint Commission accredits nearly 16,000 health care organizations in the United States and many other countries. By asking for accreditation, Naval Hospital Bremerton agreed to be measured against national standards set by health care professionals. An accredited organization substantially compiles with Joint Commission standards and continuously makes efforts to improve the care and service it provides.

"You should all be very proud of your work and our command. We clearly reaped the rewards of a long period of preparation and diligence. I couldn't be more proud of you - it is a privilege of the highest order to be your CO," stated Culp.

For more news from Naval Hospital Bremerton, visit www.navy.mil/local/nhb/.