By Inkyeong YunApril 9, 2019
U.S. ARMY GARRISON-YONGSAN CASEY, SEOUL, KOREA -- The Brian Allgood Army Community Hospital (BAACH) successfully earned accreditation from The Joint Commission (TJC), by demonstrating its compliance with their national standards for health care quality and safety in hospitals.
BAACH underwent a rigorous on-site survey, March 26 to 29 by a multi-disciplinary team of five surveyors comprised of highly trained doctors, nurses, hospital administrators and other health care professionals. The survey team spent four days inspecting the hospital as well as its outlying health clinics located at U.S. Army Garrisons Humphreys and Casey. All staff members, comprised of military, Department of Defense civilians and local national employees, participants throughout the process.
"Passing TJC with no conditional findings are achievements we value," said James Jones, the BAACH Deputy Commander for Quality and Safety. "However, it is never the end goal for us. In fact, we treat these surveys as catalysts for finding new opportunities for improvement."
"Our patients count on us to continually make strides to improve the quality of the health care we deliver. Earning accreditations and passing inspections are critical to maintaining our beneficiary population's trust on the medical care they receive," added Jones.
Through the survey process sharing "a day in the life" of BAACH, the staff was able to prove its daily dedication and determination to becoming a high-reliability organization.
The surveyors evaluated the hospital for compliance with standards of care specific to the needs of patients, including, provision of care, treatment and services, infection prevention, leadership, medication management and environment of care. During the survey, surveyors arbitrarily selected patients and used their medical records as evidence to evaluate standards compliance. As the surveyors traced a patient's experience in a health care organization, they talked to the doctors, nurses, and other staff who were involved in providing the care for the patient.
The survey showed that BAACH staff members steadily demonstrated the organization's commitment to the high-quality and safe patient care provided to all health care beneficiaries on the Korean peninsula.
The efforts of members of BAACH to own the "Just Culture" didn't begin and end with the survey team's visit. Throughout the accreditation cycle, BAACH utilized a self-assessment scoring tool to help monitor their ongoing standards compliance and TJC accreditation that permeates into the fabric of BAACH's daily operations.
Col. Andrew L. Landers, the BAACH commander, explained "Just Culture" by way of illustrating what BAACH is striving to achieve.
"This is a learning organization, willing to learn and grow as BAACH continues to strive for excellence by consistently improving and working hard every day towards achieving zero patient harm," said Landers. "People make errors. Errors can cause accidents, and, in health care, those result in morbidity and adverse outcomes and sometimes in mortality."
"A 'Just Culture' balances the need for an open and honest reporting environment with the end of a quality learning environment and culture rather than punitive actions. 'Just Culture' requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees. We are a learning organization with an emphasis on 'Just Culture,'" emphasized Landers, who shared how proud he was of the team's professionalism and efforts during this survey.
The BAACH is scheduled to close its doors on USAG Yongsan later this fall, with the beginning of outpatient and specialty care clinics being moved to USAG Humphreys. The new Brian D. Allgood Army Community Hospital will host a memorialization/dedication ceremony on Sept. 20 with a first patient day on Nov. 15. Once new patients are seen, the new facility will undergo its TJC certification 90 to 180 days later.
TJC is an independent and not-for-profit organization that accredits and certifies more than 20,000 health care organizations and programs within the United States. TJC accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting performance standards. To earn and maintain TJC's Gold Seal of Approval, an organization has to undergo an on-site survey by a TJC survey team at least every 36 months, and the regular visit is unannounced.