UC Davis Medical Center received its best-ever review by surveyors from the Joint Commission on Accreditation of Healthcare Organizations after their site visit last week.

"Every member of our team --- nurses, physicians, ancillary staff, support staff, everyone --- demonstrated personal professionalism and genuine dedication to quality of care and patient safety during this intensive review," said Robert Chason, chief executive officer of the medical center. "As a result, the surveyors were very complimentary of our team and praised the passion and skill with which our staff approaches its work."

JCAHO surveyors received an early glimpse of the staff's commitment and team spirit on their first day, when they arrived at the hospital and were unsure of where to go. Noticing their uncertainty, Ricardo Espinosa, a custodian with Environmental Services, introduced himself and walked the surveyors to their destination.

The JCAHO surveyors' preliminary report lists only three "requirements for improvement" in these areas:

• completion of an appropriate history and physical within 24 hours of a surgery or other procedure;
• timely termination of unauthorized staff members' access to electronic medication systems; and
• compliance with regulations of Clinical Laboratory Improvement Amendment (CLIA) provider-performed microscopy tests.

Medical center staff took corrective actions on the latter two items while the JCAHO survey was in progress. Within 90 days, the medical center is required to submit a report to the joint commission describing the actions it has taken to comply with the requirements. Four months later, the medical center must submit another report with quantifiable data to demonstrate that the deficiencies identified by the joint commission have been corrected. After JCAHO rates the medical center as "compliant" with all standards, the medical center's accreditation will be renewed for three years.

In addition to the three requirements for improvement, the JCAHO surveyors noted seven "supplemental findings" that suggest improvements in these areas:

• reviewing orders for appropriateness and accuracy prior to patient care;
• post-procedure/post-operative notes;
• infection control;
• outpatient problem list (a diagnostic sum-mary);
• narcotic waste;
• range orders; and
• crash cart checklists.

During their visit, the JCAHO surveyors pursued a new "tracer" process that involved selecting a patient case at random and reviewing all services provided to the patient as he or she moved through different areas of the hospital.

Allan Siefkin, chief medical officer of UC Davis Health System, said, "I spent the entire week with the JCAHO physician reviewer and I was impressed with the desire to discover areas where we could make our systems work better to improve patient safety and quality of care. I never felt they were trying to catch us on some insignificant regulation.

"I was equally impressed with our staff. It was obvious that our employees are proud of their work and proud of the organization."

Leslie Navarra, manager of the Medical Staff Administration, said the mood of last week's survey differed from previous visits because the surveyors circulated among hospital units and clinics, talking to patient-care providers about patients and their treatment.

"There was a real sense of teamwork and pride in our institution," said Navarra. "The surveyors commented repeatedly about the wonderful staff and excellent care. Even patients interviewed were glowing in their praise."

"Many staff got the opportunity to talk with surveyors about their jobs and how well they do their jobs," said Geneva Harris of the Clinical Affairs Division. Each staff member who interacted with a surveyor in the tracer process received a special badge that read, "I've been traced," with stars added on repeat tracer visits.

"Staff were proud to display their badges and became quite competitive about the number of stars they had received," Harris said. Clinical Affairs will be working with different departments and services to address the areas identified for improvement. The division also will engage in new activities aimed at maintaining a continual readiness for JCAHO surveys.

The survey just completed is the last such scheduled visit by JCAHO. The commission has announced that after 2005, its surveys will be conducted on an unannounced basis.