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Naval Health Clinic Oak Harbor Receives Positive Feedback from Accreditation Survey

Story by Patricia Rose
Naval Health Clinic Oak Harbor

Naval Health Clinic Oak Harbor (NHCOH) staff members received welcome news on 22 June when they learned they had successfully completed a Joint Commission (JC) and Navy Medicine Medical Inspection General (MED IG) accreditation survey and inspection process.

NHCOH, the first Medical Treatment Facility (MTF) in the Department of Defense (DoD) to undergo a JC accreditation survey/MED IG inspection using the DoD’s new electronic health record, Military Health System (MHS) GENESIS, was also the first MHS GENESIS MTF to successfully undertake a Primary Care Medical Home (PCMH) survey which they passed with zero findings.

“The fact that we had no high risk findings at the conclusion of several years of significant Information Technology (IT) changes, the most obvious being the fielding of MHS GENESIS, along with multiple departmental moves, construction noise/delays, leadership changes and rebranding with the new name, is truly incredible. Our dedication to each other and our patients shone through as we welcomed the JC Surveyors and the MED IG inspectors and showed them how we keep our patients and ourselves safe every day,” said Capt Christine Sears, NHCOH Commanding Officer.

Of particular note was that JC surveyors found no significant problems with such major areas as leadership, administrative, infection control, emergency management, and provision of high quality care. NHC OH Infection Preventionist, Ms. Krista Burckhardt, RN, was recognized for having spearheaded the implementation of an antimicrobial stewardship program, ensuring the safe and effective use of antibiotics, including a focus on avoiding harm that may result from antibiotic overuse.

In addition, there were several “Bravo Zulu”, or Well Done acknowledgements that went to a number of NHCOH programs and staff, such as the Civilian Drug Free Workplace Program maintained by Passion Kuntzsch; Michelle Smith and Jaci Swankie for their Shipshape, Wellness and Tobacco Cessation Programs; Robert Digirolamo for his Contracting Officers Representative Program; Carol DiCerto for her TAD process improvement; and the Information Security Program maintained by Mike Timm. HM1 To, HM1 Manila and HMC Stuttle were all recognized for their Hospital Corpsman Skills Basic (HMSB) Program as well as HM1 Manila and HMC Alfonso for their Urinalysis Program. HMC Alfonso also received Kudos for his Physical Readiness Program. The Physical Evaluation Board Program, managed by Traci Conroy & Ariel Magdalera received recognition as well as the Command’s Diversity Program, maintained by LCDR Edmondson. The Crisis Response Team, led by HN Froemel and the Command Indoctrination Program, led by HM1 Robinson both garnered high praise from the inspectors. Duty driver HM2 Arnold, was hailed as being one of the most prepared and knowledgeable duty drivers the team had experienced to date.

Another form of recognition is to be presented with a MED IG coin, and several of our staff were on hand to accept that honor, like LT Wilcox for his leadership of the Human Resources Dept., MA2 Bouscher for her Physical Security/Antiterrorism Programs, HM3 Ramirez’s Victim Advocate Program and Ms. Lisa Dalton for overall MEDIG Coordination and Command Preparedness.

The entire purpose of the JC and Med IG inspections was to evaluate the compliance of NHCOH with nationally established JC and Navy standards. The results then determine whether, and the conditions under which, accreditation should be awarded to NHCOH.

According to Cmdr. C.J Kucik, NHCOH Chief Medical Officer, surveyors and inspectors from the visiting survey teams commented on the exceptional professionalism and dedication of the staff. “They continued to perform their daily duties at the same high standard as always and were not overwhelmed being in the spotlight of inspection. That is the very essence of a Highly Reliable Organization (HRO) and I’d like to extend my sincere appreciation for everyone’s sustained level of effort and professionalism culminating in last week’s success,” Kucik said.

By continuing to be an accredited organization, NHCOH enhances community confidence, stimulates the organization’s quality improvement efforts, aids in professional staff recruitment, provides a report card for the public, offers an objective evaluation of the organization’s performance, and provides a staff education tool.

“I’d like to thank everyone who helped make this space shine, both physically, and with your warm welcoming attitude. It set the tone for learning and collaboration, rather than adversarial inspection. From the moment we greeted the team, the surveyors were smiling because of your dedication and positive first impression”, said Command Master Chief Stanley Kaneshiro.

There is a difference between the JC and MED IG survey teams, although their focus can and does overlap at times.

The JC Survey takes place every three years and is a hospital accreditation carried out by a civilian organization based on demonstrated high standards of patient safety and quality. JC standards deal with organizational quality of care issues and the safety of the environment in which care is provided. The surveyors evaluated specific NHCOH’s compliance with established standards and identified strengths and weaknesses. The overall goal was not only to find problems, but also to provide education and consultation so health care organizations could improve.

The Med IG inspection also takes place approximately every three years to assess a command’s effectiveness, efficiency, readiness, capability, and quality of healthcare services in accordance with Secretary of the Navy, Office of the Chief of Naval Operations and the Navy’s Bureau of Medicine and Surgery (BUMED) directives and instructions. Med IG also assesses interoperability, integration and collaboration with DoD, other federal government, and civilian organizations.

The JC accredits nearly 16,000 health care organizations in the United States and many other countries. The DoD uses accreditation as a benchmark for national standards set by health care professionals. An accredited organization such as NHCOH substantially complies with JC standards and continuously makes efforts to improve the care and service it provides.

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