UCSF Medical Center Wins Full JCAHO Accreditation

January 31, 2007
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UCSF Medical Center has received a full, three-year accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), according to Chief Executive Officer Mark Laret.

"I believe we have turned a corner at UCSF," he wrote in an email. "Not only have we moved toward being constantly ready for joint commission surveys, we have made significant progress toward putting the quality, safety and care needs of our patients first in everything we do. Speaking on behalf of the tens of thousands of patients who will put their health and their lives in our hands this year, I want to say 'thank you.'"

UCSF Chancellor Mike Bishop commended Laret and the medical center team. "The successful accreditation represents the staunch commitment of the entire medical center organization, including physicians, nurses, staff, residents and fellows, to meeting the highest standards of medical quality, safety, and patient centered care."

Last week, eight JCAHO surveyors visited all of UCSF's inpatient and outpatient units and its home care agency, and reviewed the medical center’s policies, procedures and bylaws.

The surveyors commented that the limited number of problems they found last week was "extraordinary for an organization of our size and complexity, and unprecedented in their experience as surveyors," Laret noted. "They complimented us over and over for the engagement of our medical staff in improving the quality and safety of the care we provide to patients, the collegiality among members of our patient care and support teams, and our obvious commitment to excellence in patient care.

"This is an enormous accomplishment of which you should be very proud," Laret noted.

Formed in 1951, JCAHO is a U.S.-based nonprofit organization with a mission to maintain and raise the standards of health care delivery through regular evaluation and accreditation of hospitals and other health care facilities. JCAHO surveyors are sent to evaluate a wide-ranging gamut of operations, from communication of caregivers to policies on medications.

JCAHO formerly scheduled evaluations, giving health care organizations a chance to prepare, but since January 2006, all surveys have been unannounced until shortly before surveyors arrive. The new survey process adds to the credibility of the accreditation process by ensuring that surveyors observe performance under normal circumstances.

Organizations deemed to be in compliance with all applicable standards are accredited. Hospitals and health care organizations are highly motivated to do well during surveys since accredited organizations are deemed by the Centers for Medicare and Medicaid Services to meet certification requirements for gaining reimbursement from Medicare and managed care organizations.

The surveyors identified a total of four "Requirements for Improvement," which UCSF Medical Center will address in the coming days, Laret said.

By contrast, UCSF Medical Center's own mock survey one year ago identified many more areas requiring improvement, he added. But after a call to action to make living by Joint Commission standards a part of the job, the entire medical center team — including medical staff leadership and clinical department chairs, supervisors and managers, charge nurses, ancillary service leaders, outpatient practice managers and facilities, IT and frontline staff — came through, Laret said.