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The Joint Comission recently surveyed our state hospital and issued a 'Condition level finding' because

the Director of Nursing does not hold a Masters Degree in Nursing and the Supervising Nurse was apparently, believed to have the advanced nursing credentials for the hospitals she provided oversight but, upon investigation by The Joint Commission surveyors it was discovered this nurse did not hold a Masters Degree in Nursing. The surveyor asked for the Director of Nursing to produce the following; - Proof that they is someone who will provide supervision that possesses the required credentials of (MSN - Proof of continuing education -Proof of acceptance into a program to obtain a MSN or Masters in Nursing - A plan that includes a time frame The Director of Nursing was able to produce a signed document from the nurse that began the same night providing supervision and her diploma and license number demonstrating an active, unrestricted license in the state -The letter of acceptance into the school the DON was returning to and the start date (even through, the surveyors stated the start semester was not on the paperwork -in was indeed clearly listed as starting in the Summer Semester. - And the notation that the Supervising Nurse would be meeting on the upcoming weekend to develop the supervisory plan and review the educational plan. Since, the actual survey the DON has solidified the educational plan and time frame; met with the Supervising Nurse; and begins classes the first week of June. However, the Hospital deputy director states TJC requires the Supervising Nurse to be a part of the state hospital system. We have inquired other Director's of Nursing who have experienced the exact or similar situation. And, all state TJC has not dictated what system the Supervising Nurse is a part of just proof that it is happening. Please, explain why some surveyors require different standards? Is it the facility?; the person?; or the surveyors interpretation. There is no mention of this type of stringent requirement with CMS who TJC surveys for with hospitals seeking 'Deemed Status.' Please, cite the language in TJC standards requiring the Supervising Nurse be a part of the hospital or hospital system, Thank you
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ID
#1545096 Review #1545096 is a subjective opinion of poster.
Junior Reviewer

The Joint Commission has little or no value.

On December 13, 2013 I mailed complaint to Ronald R. Peterson, President,The Johns Hopkins Hospital and Health System, Maryland Department of Health & Hygiene Office of Health Care Quality, The Joint Commission Office of Quality Monitoring and Stacy BaldwinAdministrative Director, Cardiac Surgery, Johns Hopkins Medicine. On December 30, 2013 I received this unsigned, anonymous correspondence from The Joint Commission: "Dear Mr. Glynn: We are writing in response to the concerns you shared with The Joint Commission. We have reviewed our records and determined that Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287 is not currently accredited by The Joint Commission. Therefore, we have no authority to evaluate your complaint. We encourage you to contact the organization directly for resolution. You may also want to contact the Maryland State Department of Health to see if they can address your concern(s). Please include the incident number indicated at the top of this letter on any future correspondence regarding this matter. Sincerely, Office of Quality Monitoring" I should have know by that reply that I was not dealing with a very competent organization. It took 5 phone calls before I was told that I needed to use the main office address not the hospital address for my conplaint to be processed. It seems like the front office need some training and supervision and maybe some competent employees. Between December 30, 2013 and February 26, 2014 I updated Incident #91938XZZ-5e2062HOQ numerous times. No updates were ever confirmed or acknowledged. February 26, 2014 I received another insulting, unsigned, anonymous form letter from The Joint Commission stating "Recently, you contacted The Joint Commission about The Johns Hopkins Hospital, a Joint Commission accredited organization. We contacted the organization regarding your concerns and asked for their written response. After our comprehensive review, we have determined that their response is acceptable at this time." The definition of comprehensive is "complete; including all or nearly all elements or aspects of something." Since I was never questioned, included or given an opportunity challenge Johns Hopkins Hospital’s response their review was one sided and protects their dues paying members. Since neither The Joint Commission or Johns Hopkins Hospital will release the result of the review I can only assume that they are hiding something from the person who filed the complaint or ashamed of what is in the report or protecting their credibility. Unsatisfied with the generic form letter of February 26, 2014 I called The Joint Commission office On February 17, 2014. I spoke to a Ms. Levi and was told was told it is your policy never to sign letters or release findings. I asked to speak with Director. I was given Anita Giuntloi’s number. Called and left voice message. Feb 28, 2014 I was called by Marie, returned the call and set up call with Anita Giuntoli, Associate Director, Office of Quality Monitoring for Monday, March 3, 2014 at 3:00 pm. March 3, 2014 Marie called and rescheduled for 1:00 today March 3, 2014, 1:00 pm to 1:45 had phone conversation with Anita Giuntoli. Went over my list, talked about The Joint Commission’s role, my concerns, and again it was stated that their policy was to never release review findings. I said I would email a file that contained all the issues we discussed and I did. March 4, 2014, this email was received: Hello Mr. Glynn, Thank you for the time and information you shared with us on the phone today. I wanted for you to know I have received your email and will initiate review and analysis. Let us know how things go with your contacting the organization. We will talk with you again towards the beginning of next week to provide an update. Again, my sincere thanks. Anita THAN NEVER HAPPENED AND NONE OF MY INCIDENT UPDATES WERE EVER ACKNOWLEDGED!March 4, 2014, this email was received: Hello Mr. Glynn, Thank you for the time and information you shared with us on the phone today. I wanted for you to know I have received your email and will initiate review and analysis. Let us know how things go with your contacting the organization. We will talk with you again towards the beginning of next week to provide an update. Again, my sincere thanks. Anita THAN NEVER HAPPENED AND NONE OF MY INCIDENT UPDATES WERE EVER ACKNOWLEDGED! On July 3, 2014 I received another letter from The Joint Commission. This letter was identical to the insulting, unsigned, anonymous form letter I received on February 26, 2014. Just exactly what did The Joint Commission do during the 18 weeks between letters? It appears to me that The Joint Commission and Johns Hopkins Hospital are on the same page when responding to patient complaints. Hear no evil, see no evil, speak no evil and if we drag it out long enough and just ignore it maybe it will go away. The Joint Commission gives hospitals many opportunities to correct their deficiencies and rarely does a hospital lose its accreditation. But during this process The Joint Commission collects large fees for reviews, consultations and any assistance they provide. It appears that financial success takes priority over patient care and safety. Why is a hospital provided so many chances to get things right and their response kept secret but the patient who filed the complaint is only worthy of an anonymous, unsigned form letter. Since neither The Joint Commission or Johns Hopkins Hospital will release any information about what was reviewed and analyzed or how the hospital responded I think is a fair assumption to think that both organizations are hiding something, embarrassed by their findings and protecting each other. Some examples of their credibility within the health community: "The fundamental structure of the Joint Commission doesn't make sense. It's one big built-in conflict, and the fact that Medicare allows it is appalling." "If you added up all the adverse events in hospitals, they would probably be about the third leading cause of death. The public should be screaming that we deserve better." "For instance, Maryland hospitals reported that none of the millions of patients treated from 2004 to 2006 suffered from advanced pressure ulcers, or bedsores, an astonishing statistic given that bedsores are a common ailment caused by lying down too long.After a push by state and hospital officials to improve reporting, the number increased to 144 in fiscal 2011 before falling to 52 in fiscal 2013. But national statistics suggest that even those figures are low. Federal data show that, on average, about 0.6 percent of patients get bedsores that progress to the advanced state — a rate that would translate to more than 4,000 cases a year in Maryland." The fact that The Joint Commission, which accredits the majority of the nations hospitals, is not a very creditable organization is scary. As far as I can tell The Joint Commission is a self-appointed organization that lives in an Ivory Tower and answers to nobody. There is no process to file a complaint about them. I updated my Incident File numerous time but the updates were never acknowledged. On July 3, 2014 I received another letter from The Joint Commission. This letter was identical to the insulting, unsigned, anonymous form letter I received on February 26, 2014. Just exactly what did The Joint Commission do during the 18 weeks between letters? It appears to me that The Joint Commission and Johns Hopkins Hospital are on the same page when responding to patient complaints. Hear no evil, see no evil, speak no evil and if we drag it out long enough and just ignore it maybe it will go away. The Joint Commission gives hospitals many opportunities to correct their deficiencies and rarely does a hospital lose its accreditation. But during this process The Joint Commission collects large fees for reviews, consultations and any assistance they provide. It appears that financial success takes priority over patient care and safety. Why is a hospital provided so many chances to get things right and their response kept secret but the patient who filed the complaint is only worthy of an anonymous, unsigned form letter. Since neither The Joint Commission or Johns Hopkins Hospital will release any information about what was reviewed and analyzed or how the hospital responded I think is a fair assumption to think that both organizations are hiding something, embarrassed by their findings and protecting each other. Some examples of their credibility within the health community: "The fundamental structure of the Joint Commission doesn't make sense. It's one big built-in conflict, and the fact that Medicare allows it is appalling." "If you added up all the adverse events in hospitals, they would probably be about the third leading cause of death. The public should be screaming that we deserve better." "For instance, Maryland hospitals reported that none of the millions of patients treated from 2004 to 2006 suffered from advanced pressure ulcers, or bedsores, an astonishing statistic given that bedsores are a common ailment caused by lying down too long.After a push by state and hospital officials to improve reporting, the number increased to 144 in fiscal 2011 before falling to 52 in fiscal 2013. But national statistics suggest that even those figures are low. Federal data show that, on average, about 0.6 percent of patients get bedsores that progress to the advanced state — a rate that would translate to more than 4,000 cases a year in Maryland." The fact that The Joint Commission, which accredits the majority of the nations hospitals, is not a very creditable organization is scary. As far as I can tell The Joint Commission is a self-appointed organization that lives in an Ivory Tower and answers to nobody. There is no process to file a complaint about them.
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ID
#525756 Review #525756 is a subjective opinion of poster.
Location
Frederick, Maryland
Reason of review
Not as described/ advertised
Loss
$250000
Preferred solution
Let the company propose a solution

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