CCH Survey Overview

Joint Commission 3-year survey summary.

The Joint Commission (JC) conducted its routine 3-year survey at Cape Cod Hospital in November 2010 and renewed the hospital’s accreditation. The team cited hand-off communication, falls prevention and infection control as examples of the quality of care the hospital provides.

“There were many stars and departments that were highlighted by the surveyors on a daily basis,” during the recent survey, said Cathy Bachert, RN, Director of Quality, Regulatory Compliance and The Patient Experience at CCH. “The staff was welcoming and warm, and it was evident how very much we care about our patients. Cleanliness in every nook and cranny was evident. The kitchen staff and work area were other examples of the attention to detail resulting in quality food preparation.” Mugar 6 was also exemplary, and all outpatient departments were without findings for two consecutive surveys.

The benefits of accreditation are:

• Strengthens community confidence in the quality and safety of care and services.
• Helps organize and strengthen patient safety efforts.
• Provides education on good practices to improve business operations.
• Provides deeming authority for Medicare certification.
• Recognized by insurers and third parties.

Among the specific areas the JC looks at in their surveys are the environment of care, infection prevention and control, medication management, record of care, treatment and services, nursing and leadership.