About every three years, hospitals and healthcare facilities across the nation take part in Accreditation Surveys performed by The Joint Commission (TJC), a non-profit organization committed to improving healthcare for the public. These surveys are unannounced and serve to evaluate the facility’s compliance with TJC’s standards which focus on patient safety and quality of care.

During Eagleville Hospital’s Accreditation Survey, which took place mid-2019, more than 1,011 TJC standards were reviewed. Of these, only 17 deficiencies (areas of improvement) were noted. This represents a TJC standards compliance rate of more than 98%.

These deficiencies included things such as updates to patient assessment tools in the electronic medical record, missing labels (full vs. used) on a few oxygen tanks and standing water in the janitor’s closet””all of which were easily and promptly corrected.

Eagleville’s strengths, as noted by the TJC surveyors, included:

• The organization’s openness and transparency with regard to sharing information
• Leaderships engagement in safety and quality improvement objectives
• Culture of safety
• Culture of learning
• Patients are supportive and complementary of the care received
• Medical and clinical staff are collaborative with quality improvement projects
• The organization is on its way to developed leading practices for treatment of co-occurring diagnoses and improvement methods in admissions using data, communication strategies, trending and continual performance improvement