Accreditation field report

Two Baptist facilities win Gold Seal status

Three years ago, when Baptist Hospital in Pensacola, FL, had its Joint Commission survey, the 392-bed facility did not have a great result. According to Wanda Kaye Tillery, BSN, MBA, vice president of quality and patient safety for Baptist Health Care and its four acute care hospitals — including Baptist Hospital — it was a big come-down from a few years earlier, when the facility won the Malcolm Baldrige award for its high quality of care. The health plan and its leadership were determined that the next survey, which took place in June 2011, would be better. They just did not think it would be so much better that Baptist and its 167-bed sister hospital Gulf Breeze — which was surveyed a month before Baptist — would achieve Gold Seal status, indicating that it met all quality standards immediately, without having to make any significant corrections.

"There was no vice president of quality three years ago, and there was not a lot of focus on patient safety at the time," Tillery says. "I was hired a year later to put an emphasis on safety and quality, and I did that from the start." First, she hired some consultants to do an assessment. They validated what the hospital had heard from Joint Commission surveyors and its Strategic Surveillance System report, as well as recent Oryx measures. "We knew some of the systemic issues we had to address early on," she says. For example, documentation was a problem, without strict discipline or adherence for inappropriate time outs or abbreviations. And with a 60-year-old building, there were considerable safety vulnerabilities.

The latter issue led Tillery to hire a safety consultant specifically to address the problems the building had. After that, there were 18 months to get ready for the next survey. "I was behind from the minute I walked in the door and I knew it," she recalls. But she had some things that were in her favor. First and foremost, her peers and superiors knew she was behind, understood that there were vulnerabilities, were unhappy with the results of the previous survey, and knew that they needed her to lead the charge to prepare for the next one. "It was a tall order to get ready and they knew it. It would have been harder if I had to do a lot of convincing."

While money doesn't grow on trees in the Florida panhandle, Baptist Health was willing to spend money to improve quality and safety. "They were willing to let me hire the consultants and make the plant modifications that were necessary," Tillery says. "Most of our electrical system was 60 years old. There were panels in the ceilings that couldn't be covered that all had to be stripped out. We had a behavioral health unit that was not purpose built whose plumbing had to be completely pulled out and replaced. Two whole wings needed to be replaced just because of ceiling issues."

Another factor in her favor was the understanding that they were doing this not for some vague reason like "standards," but for the safety and health of patients and staff. "The environment in Florida isn't always kind to buildings," she says. "The buildings were a real concern. It made it easier for everyone to get behind."

As difficult as the building situation was, so was the documentation on life safety issues. Code books, manuals, plans — it all had to be created or recreated. A consultant helped with that, and money had to be spent to get it done.

If time was not on her side, the culture was. "When we won the Baldrige award and won Press Ganey awards for patient satisfaction, it reinforced our culture of just getting it done and doing it together. There is a high level of engagement among the staff." Getting ready for the survey required all hands on deck, and those hands came willingly. "Once we communicated the issues and the solutions, there were no questions. People just buckled down and did it. I did not have to resort to begging or pleading or threats. Every single person wanted us to do well. They knew this was about creating patient-centered care, and that is everyone's quest here."

Medical staff were happy to pitch in, too. As long as they knew the rationale behind an initiative, they were happy to help. Often, they came up with their own suggestions — tools, order sets, forms, or stamps that would prompt them to create the best documentation they could.

For instance, the time-out issue resulted in conversations between surgical staff — not about major issues, but nuances, says Tillery, such as whether to start over when any other team member comes in the room. "The issue isn't about not wanting to do a time out or not, but about surgeons and other staff being clear about when it starts or needs to restart."

Medical staff also received more feedback and data on their performance in the run up to the survey. "They used this so that if there was an outlier, they were told and coached for improvement," she notes.


Tillery says she's participated in Joint Commission surveys for years, and what struck her more this time than any of the other ones she has had is how much more attention the surveyors paid to the compassion and care given to patients, as opposed to focusing solely on the standards. "They knew the standards; they scored by the standards, but rather than rigidly focusing on them, they looked at various situations and circumstances and praised and complimented staff about what they were doing. They talked about how much the compassion staff showed mattered in terms of keeping patients safe." Tillery says surveyors seemed to look more at the bigger picture of healthcare as it is delivered rather than at the minutia of the standards. Again, she emphasizes that the standards and meeting them was vital. But they were noticing other things in addition to adherence to standards.

Tillery thinks this is something that has changed at The Joint Commission itself, not just among the surveyors she dealt with. "I went to a hospital in Mobile [AL] during its survey," she says, noting that she is part of a consulting consortium that supports such visits to increase knowledge among members. "They were different surveyors, but seemed to be doing the same thing: paying attention to standards and conditions of participation, but also the quality of the work they do with patients." Her peers are saying similar things.

An example of what she experienced came from a particular surveyor who asked everyone she talked to, "What would you ask of me for the benefit of the patient? How can I help you take care of your patients better?" Tillery says that she found that kind of question "new, different, and refreshing. I felt like they had the same goals we had, and it reinforced what we tell our staff and employees: that this is all about the patients. It made the survey something other than a test, but reinforcement for our clinicians."

Tillery made sure to tell the surveyors when they left that they had helped further the cause of patient safety by creating a great enthusiasm, particularly among the nurses, for everything they did. "There was no collateral damage here, but collateral benefit, and a benefit we really can't measure."

Being awarded Gold Seal status was a "pleasant surprise," Tillery says. "I'm paid to be a pessimist. There were things we had been working hard on but I was not sure we were there yet." Documentation was one issue she worried about. "We had been looking at data, had a great, tight feedback loop, and we knew what was in our charts. But one doctor on a bad day can make a slip. No one is perfect all the time." There were also concerns in the life safety area, but they had a rigorous surveyor and found just a single ceiling area with uncovered electrical panels that had to be fixed. "They were very complimentary of our plans, documents, and risk assessments. We did a lot of hazard vulnerability analyses and they weren't collecting dust on a shelf. We were actively working to make our plant safe."

The overall feedback both hospitals and their staff got from the survey was positive and consultative, Tillery says. "They were interested in sharing knowledge and teaching us. I had told our board that I wanted The Joint Commission to find us to be a best practice in something that The Joint Commission could take forth and share with others." Tillery is waiting to see if that happens, noting that the surveyors took the ongoing professional practice evaluation and focused professional practice evaluation from the medical staff chapter with them to share with their superiors. She hopes to find it on the Best Practice portal at the Joint Commission website soon.

After a poor showing three years ago, for two hospitals in the system to have full accreditation the instant the surveyors left was a great feeling, Tillery says. More than a just bonus to tout to potential patients, it is a great thing to share with the staff. "We had an unpleasant survey three years ago, and we had worked very hard to get this far. That immediate gratification and reinforcement meant a lot to all of us. We are a small enough community to know that another system in our area had surveyors leave without that full accreditation. It was great to know that we give quality, safe care."

The surveyors made the announcement of Gold Seal status at a Friday afternoon meeting. Everyone who could show up did. The surveyors provided feedback and again talked about how the compassion for patients and the passion for quality care "exuded" from the staff, Tillery recalls. "We were wowed by what they said. We are still celebrating it."

There is no back to normal. While Tillery says they are "still riding the high," the Monday after the survey is business as usual. "There are always people giving patient care here, and it is nice to have that validation that it is good care. But the to-do list is still there. We haven't stopped our monitoring and our feedback. Maybe the intensity isn't as high, but we still monitor. We still have our meetings of all the committees we had before the survey. You can't stop this."

For more information on this topic contact Wanda Kaye Tillery, BSN, MBA, Vice President of Quality and Patient Safety for Baptist Health Care, Pensacola, FL. Telephone: (850) 434-4011. Email: