UMC takes aggressive plan to fix accreditation problems

University Medical Center has implemented an aggressive, swift plan to keep its accreditation after the Joint Commission, or JHACO, which accredits hospitals, last week found major problems at the County Hospital.

UMC CEO Jim Valenti in a letter to stakeholders on Sunday said many departments and individuals had been commended and recognized by the Joint Commission but that had been overshadowed by the performance of the Sterile Processing Department.

UMC’s plan of action, implemented as early as Friday night includes adding extra staff to the troubled department, ensuring nurse managers are overshadowing the current employees. UMC has also hired two outside expert companies, Integrated Medical Systems and Top Echelon Contracting to oversee and train employees on sterile processing and infection control.

“They’re going to have these two different third parties in addition to their added personnel internally so it’s a multi-pronged approach because the goal is to get JHACO in before the 23 days,” said County Judge Veronica Escobar on Monday who had been briefed by UMC officials on the situation.

The county hospital will also work toward all department management attaining certification status, something not required by the Joint Commission but still strived for by UMC.

Valenti also said the hospital will begin monthly internal reviews and hired a company to recertify all the sterile processing equipment.

“I don’t think it should have happened in the first place but I do think we’re on the right path to get it taken care of,” said Commissioner David Stout on Monday.

The Joint Commission found four main problems with the hospital’s sterile processing department including employees not following procedures, not documenting their training and not properly conducting routine maintenance following manufacturer guidelines.

Katherine Bronk, a Joint Commission spokeswoman on Monday in an email wrote that accreditation reports are confidential but the hospital’s compliance with National Patient Safety Goals is available to the public.

“From July 6-10, 2015, a routine onsite survey was conducted at University Medical Center of El Paso. During the survey, The Joint Commission found an immediate threat to the health or safety of patients, staff or the public within the hospital,” wrote Bronk.

Before the Joint Commission went to UMC for the official inspection, the hospital did what UMC Spokesman Ryan Mielke called a “dress rehearsal”, in which it hired a consultant to do a mock inspection.

That inspection found issues like accumulated dust or dried blood in some areas. Mielke said the issues from the “mock” inspection were fixed before the actual inspection by the Joint Commission.

People who were scheduled for non emergency surgery at UMC can either reschedule it, try to get it at another hospital or sign a waiver acknowledging the problems found by the Commission.

It’s unclear how much money UMC will lose from suspending elective surgeries.