News basks in glow of Joint Commission review

Friday, April 5, 1996

Hospital’s rating upgraded from ’95 conditional statusBy Donna
Wong

Special to The Bruin

After nursing wounds from an investigation prompted by a patient
complaint, UCLA’s Neuropsychiatric Institute Hospital (NPIH) is
back on track again with a glowing review and full three-year
accreditation.

Recently, the hospital, which specializes in the housing and
care of psychiatric patients, received official notification of
"accreditation with recommendations for improvement," said Alice
Brown, communications representative for the Joint Commission on
the Accreditation of Healthcare Organizations (JCAHO).

Out of a possible 100, the neuropsychicatric hospital received a
score of 91. Under normal circumstances, this score would qualify
the hospital for accreditation with commendation, the highest level
of accreditation awarded to hospitals that demonstrate exemplary
performance in areas ranging from patient care to hospital
structure.

But because the hospital was constructed to old building code
standards and earthquake damage has aggravated the current physical
structure, the Joint Commission made recommendations to improve the
hospital’s physical plan, said Don Rockwell, chair of the Quality
Improvement Council, which oversees the monitoring of hospital
performance.

"We’re all very pleased that the accreditation was successful
and (JCAHO) was very complimentary toward the entire organization,
physicians and staff," said G. Michael Arnold, the hospital’s
interim director and chief administrative officer. "I was proud of
the organization in how it pulled together and responded very
effectively to the whole accreditation process."

The Joint Commission, a Chicago-based organization that reviews
overall healthcare performance at more than 11,000 institutions
every three years, awarded the UCLA neuropsychiatric hospital with
"conditional accreditation" last year.

In November 1993, a patient committed suicide, allegedly hanging
himself with a belt while in a maximum security ward. A patient
complaint, apparently related to the death, prompted the commission
to conduct an unannounced survey in June 1994 about the
incident.

After a provisional ruling of conditional accreditation, the
hospital requested a validation survey to clarify the findings from
June and reverse the commission’s initial findings

Yet in spring 1995, the Joint Commission officially awarded the
hospital with conditional accreditation in reference to the June
1994 survey.

According to commission language, the rating indicates marginal
hospital performance under commission standards, or that one or
more serious events have occurred for which the hospital can be
held accountable. Although the hospital remained accredited during
the year, they were required to demonstrate that they had corrected
problem areas through a follow-up survey six months after the
official commission ruling.

The last visit from the commission occurred Aug. 2, 1995,when
the hospital underwent its usual accreditation survey scheduled for
every three years. The hospital passed that survey with ease.

"It’s really a validation that we do provide quality services,"
Arnold said. "Regaining our accreditation was a validating point to
us."

Although the hospital is reviewed externally by the Joint
Commission, the neuropsychiatric hospital also has its own internal
review and improvement process headed by the Quality Improvement
Council.

Chaired by Rockwell, the council is constantly involved with the
on-going process of gathering data and information about patient
satisfaction and staff care, and then acting on their findings. The
council’s job is to make sure the UCLA hospital lives up to the
Joint Commission’s standards and keeps up with any changes.

More recently, the commission began focusing primarily on actual
outcomes as opposed to assessing an organization’s theoretical
ability to provide quality care.

"(JCAHO’s) assessment is just to make sure that we’re looking at
all the areas we should be looking at, so we can identify problems
before they happen. And if they do happen, (it ensures) we have
processes in place so we can quickly correct them," Rockwell
said.

Currently, plans are in the process for the construction of a
new medical center and neuropsychiatric hospital. As opposed to
seismically renovating the entire NPIH under the Joint Commission’s
recommendations for improvement, hospital administrators have
decided to construct a new one instead. Completion of the project
is scheduled around 2002.

Now that the neuropsychiatric hospital has regained its full
accreditation, hospital administrators said that it is nice to have
the last year and a half behind them.

"It was one hurdle we had to get over, and we did," Arnold
said.

Rockwell added that the attention given to the June 1994 survey
results has made many overlook the actual level of quality and care
UCLA’s neuropsychiatric hospital offers.

"I’ve always felt that we just got a terribly bad rap, as far as
the (June 1994) unannounced survey … There was never any doubt in
my mind as far as the outcome of the entire situation. There’s
never been any doubt that we are at the forefront in quality review
programs," he said.