Intermountain Medical Center’s spine program earned a rare “no findings” report from the Joint Commission in August.
Post-Anesthesia Care Unit from Intermountain Medical Center's spine program
Kathryn Marshall, clinical initiatives manager, says the Joint Commission reviewer noted it was only the third time she’s given a rating of “no recommendations for required findings.”
Many of the program’s processes were at an Advanced Certification level, according to the reviewer, who observed high levels of collaboration and a passion for patient care. She also praised the team’s great documentation, its culture of process improvement, and the way education is systematized.
IMED’s Spine Program, under the leadership of John Macfarlane, MD, associate medical director, tracked four measures for this review: opioid use, infection rates, patient experience, and sleep apnea evaluation.
“This was my first experience with a Joint Commission survey,” Dr. Macfarlane says. “As I spent the day with the surveyor, I was in awe of our great team. The surveyor interviewed, quizzed, and questioned caregivers from each part of the spine patient’s journey—the pre-operative, peri-operative, and post-operative care areas. Each caregiver spoke knowledgeably and passionately about the great care they provide for our patients. I’m grateful to be a part of this team and thank the team members for their ongoing contributions to our program.”
Dr. Macfarlane has been tracking and working on these measures for several years, so the team was in a good position to report to the reviewer on the last nine months.
“We were ready for them,” Kathryn says. “They talked to providers in each area, asking them what they do with the spine patients and what their hand-off process was.”
Areas included in the review were Same Day Surgery, Pre-operations, Post-Anesthesia Care Unit, Operating Room, and the Neuro/Med Unit.
Along with interviewing caregivers, the reviewer also looked at several charts and the chart of a current patient and even talked with the patient, who observed that it was “the best surgery I’ve ever had,” and gave the team a “gold star.”
IMED is the fourth Intermountain hospital to institute a spine program, after St. George, Utah Valley, and McKay-Dee hospitals.