Accreditation week

We had a pretty full inspection schedule last week. It wasn’t our goal to have three separate accreditation visits in a single week, evaluating various aspects of our clinical programs, but that’s how it worked out. The Cancer Center had inspectors on campus to renew the formal accreditation for our bone marrow transplant program (Federation for Accreditation of Cellular Therapy), our breast center (National Accreditation Program for Breast Centers) and our overall cancer care delivery program (Commission on Cancer). Although we will not have formal reports for a number of weeks, I am pleased to say that all three visits appeared to go extraordinarily well.

We know we provide outstanding care for our patients, but these organizations don’t take our word for it. Each of these organizations has established precise standards and rigorous requirements for documentation of these standards. The inspectors evaluated our formal Standard Operating Procedures to assure our standards comply with their requirements, and inspected patient records and other documents to assure we were following our own procedures accurately. The standards are constantly being updated, and we needed to be sure our procedures kept up. Finally, the inspectors evaluated our performance and outcomes, and compared it to data from other institutions across the country.

Going into the inspections, I was confident we would do well. We have outstanding teams and leaders who had been preparing for these visits for months.

Some of the preparation involved “sweating the small stuff,” such as making sure the needed information was in the right format for the inspectors to review. This was, at times, tedious, but was nonetheless vital if we were to have positive reviews. Attention by our staff to this sort of detail reflects their attention to detail in patient care and their dedication to a job well done. Thus, I had no doubt the files would be in order.

Other aspects of the preparation were more substantial in that they are part of our ongoing efforts to assure we provide top quality care. This includes reviewing current Standard Operating Procedures to assure they have been updated and are being followed. Indeed, a very positive aspect of the accreditation process is that it requires us to periodically review our Standard Operation Procedures to assure they match (or exceed) national standards and that our approach to patient care is consistent with our written procedures.

Accreditation week is now over, much to the relief of many members of our team. It is good to come off the week feeling it went very well and knowing we won’t have to worry again about inspectors rummaging through our files and looking for dirty laundry for some time to come (maximum accreditation for each of these groups is three years). However, the hard work of assuring we provide top quality care to our patients, and our ongoing quality improvement efforts are never ending.

Many thanks to all members of the team for all the outstanding work, dedication and attention to detail they put into last week’s successful inspections, and more importantly, for the outstanding work you do every day for our patients.