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Hospital works to ensure regulatory readiness

The year 2013 is shaping up to be a big year for accreditation and licensure surveys for the newly integrated Yale-New Haven Hospital.

YNHH's ability to provide care to patients depends on the approval of three chief regulatory agencies: The Joint Commission (TJC) is the hospital's accrediting body; Connecticut's Department of Public Health (DPH) licenses Yale-New Haven; and the Center for Medicare and Medicaid Services (CMS) certifies the hospital's ability to care for their patients. Each agency surveys YNHH at different intervals and none gives advance notice of its specific survey visit dates.

"During their surveys, each agency focuses on different areas of compliance, but they all work to ensure that YNHH is meeting fundamental safety and quality standards," explained Victoria Dahl Vickers, RN, MBA, director, Accreditation, Safety and Regulatory Affairs.

The upcoming surveys expected this year include:

  • TJC Accreditation Extension Survey at the Saint Raphael Campus (SRC) which may also include the Smilow Cancer Hospital Care Centers; YNHCH at Bridgeport; and the YNHH Spine Center at Long Wharf. The survey visit can occur anywhere between now and mid-May.
  • The DPH re-licensure at all YNHH campuses has a survey window anticipated between May and August.
  • TJC Tri-Annual Hospital Accreditation Survey at all YNHH campuses is expected to occur between October and December.

After the hospital's integration in September, YNHH engaged several consulting groups to provide an overall assessment of readiness on the Saint Raphael Campus.

"While the findings indicated many areas in which we do very well, it also provided us with a number of areas for improvement. As we prepare for surveys, we will use the findings to help us make improvements in the key areas identified," said Vickers.

Over the coming weeks and months, the Department of Accreditation, Safety and Regulatory Affairs will introduce and coordinate a number of initiatives to help employees prepare for these important surveys, with the ultimate goal of having YNHH in the best shape possible to provide the highest level of patient care.

Hospital leaders will ramp up rounding and share educational, training and briefing materials with employees covering an array of topics with consistent information on key issues, such as the environment of care, National Patient Safety Goals and medication management.

On January 17, the hospital hosted an accreditation readiness fair on the Saint Raphael Campus for information sharing. Employees will begin to receive the electronic newsletter, Frontline News, which will provide the latest information on patient safety and quality issues.

"Owning safety and quality practices is everyone's responsibility," added Vickers. "Preparation is not only about getting ready for surveys — this is for every day, so we are prepared to care for patients in the safest, most effective and highquality manner possible."

Yale-New Haven Hospital news release

Yale-New Haven Hospital is a nationally recognized, 1,541-bed, not-for-profit hospital serving as the primary teaching hospital for the Yale School of Medicine. Yale-New Haven was founded as the fourth voluntary hospital in the U.S. in 1826. Today, the hospital's two New Haven-based inpatient campuses include Yale-New Haven Children's Hospital, Yale-New Haven Psychiatric Hospital and Smilow Cancer Hospital. YNHH has a combined medical staff of about 4,500 university and community physicians practicing in more than 100 specialties. YNHH's York Street campus and associated ambulatory sites are Magnet-designated by the American Nurses Credentialing Center.

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