The Joint Commission visited UTMB in late November, and has issued its final report of survey findings. To put the survey into context, UTMB was measured against 247 standards for compliance and more than 1,200 elements of performance.
There are two levels of Requirements for Improvements (RFIs) for which an institution may be cited by Joint Commission: a direct RFI or an indirect RFI, depending on the immediacy of risk to patient safety and quality of care.
While there were findings during the survey, UTMB received only four direct RFIs and 11 indirect RFIs. A previously reported fifth direct RFI has been removed by Joint Commission.
"This is an excellent outcome, and you all should be very pleased with this recognition and the care that we provide our patients,'' said Donna Sollenberger, Executive Vice President and CEO, UTMB Health System.
UTMB has 45 days from the date of the report to respond with an implemented corrective action plan for direct findings, and 60 days for indirect findings. A four-month tracking period to demonstrate that the corrective action has been implemented and sustained will follow, and that data submitted to Joint Commission.
Surveyors were very complimentary of many of the areas they surveyed and commented on the excellent communication among staff and leadership. They recognized the camaraderie and collaboration at UTMB, and also commented positively on UTMB's openess and transparency.
The survey achieved its purpose in that a group of individuals from outside our institution reviewed our care processes and provided excellent feedback on how we can improve, Sollenberger said. "We will use the final survey to do just that.''
"Thanks to everyone for their excellent participation,'' she said. "We are extremely proud of all of our phyisicians, nurses, residents and staff who did so well in showing the many positive aspects of UTMB. This was truly a UTMB team effort, and once again shows we are Working Together to Work Wonders! "