The Department of Hospital and Clinics undergoes triennial accreditation and licensing surveys by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the State Department of Health Services (DHS), and the California Medical Association (CMA). The combined licensing and accreditation survey (CALS) by the three organizations requires extensive preparation by hospital administration and medical staff to achieve the full accreditation status necessary for patient care reimbursement by Medicare, Medi-Cal, and other third party payers.
Because the JCAHO standards are revised and broadened annually, it is difficult to remain current with all required standards. In the last year there have been significant changes in regulatory agency standards. New standards are throughout the entire JCAHO manual in the areas of Emergency Management, Patient Safety, Disclosure to Patient/Patient's Families and Staff effectiveness. The State of California for 2002 has also mandated a medication error reduction program for hospitals. Meeting new standards are further challenged with the changes that are occurring at the Hospital/Clinics. New services, i.e. Methadone Program increase our need for compliance to new standards for new programs.
Quality Systems Group, LLC has an excellent working knowledge of our organization. They are responsive to our needs and available by telephone, e-mail and onsite visits. For several years, the Department of Hospital and Clinics has utilized Quality Systems Group, LLC, to assist with the preparation and maintenance of its accreditation program, and to design and implement JCAHO standards related to improving organizational performance.
The Hospital was surveyed by the JCAHO in June 2001. There were 13 surveyors that surveyed all of our services over the span of four days. Out of a possible score of 100, Acute Care scored 82, Long Term Care (LTC) scored 93 and the Laboratory scored 97. As a result of the extensive preparation under Quality Systems Group's guidance, the Department received a three-year (the maximum) accreditation. |
In April 2002, the Department of Hospital and Clinics issued a Request for Proposals (RFP) for provision of consultation services for performance improvement. Of three responses received, Quality Systems Group, LLC was selected based on providing the lowest cost while ranking highest in the following criteria: accreditation survey compliance preparation; regulatory agency compliance; performance improvement; organization and governance; clinical pathways; medical staff management; management development; environment of care assessment; risk management program; patient satisfaction program; references; proposed in-services; and availability and frequency of visits. |
The term of the agreement is three years, from July 1, 2002 through June 30, 2005. The agreement contains a mutual 30 days cancellation clause. The agreement maximum is $220,000. Funds are included in the FY2002-03 Hospital and Clinics approved budget and will be included in subsequent requests. |
