Walter Reed, programs reaccredited by The Joint Commission

Walter Reed National Military Medical Center recently received formal notification of its reaccreditation by The Joint Commission (TJC) for the hospital, Primary Care Medical Home (PCMH) and Behavioral Health.

Walter Reed earned TJC’s Gold Seal of Approval “by demonstrating continuous compliance with its performance standards. The Gold Seal is a symbol of quality that reflects a health care organization’s commitment to providing safe and quality patient care,” according to Dr. Ken Grubbs, executive vice president of Accreditation and Certification Operations and chief nursing officer for TJC.

Walter Reed underwent an onsite review July 16-19. During the visit, TJC reviewers evaluated Walter Reed’s compliance with national patient safety goals, medication management, provisions of care, human resources, leadership, infection prevention and control, life safety, and environment of care, according to Dr. Felicia Pehrson, Walter Reed’s chief quality officer at the time of the review, and Victor Mosley, chief of Performance Improvement at Walter Reed.

TJC’s standards are developed in consultation with health care experts and providers, measurement experts and patients, Grubbs explained. “They are informed by scientific literature and expert consensus to help health care organizations measure, assess and improve performance. The surveyors also conducted onsite observations and interviews,” he added.

“Walter Reed maintains its mission of always being survey-ready, every day of the year. We aim to provide the best patient care in the world to our unique patient population, so we always work to be in compliance, even when we are outside of the survey window,” Pehrson and Mosley explained. “We run ‘Just Do It’ tracers, command tracers, and environment of care tracers to ensure we are always in compliance,” they added.

Mosley shared that Walter Reed brought in an outside consulting group to conduct a mock survey in early 2024. Pehrson added that Walter Reed’s Quality representatives throughout the hospital work hard daily to address any observations and develop sustainable action plans to maintain compliance with TJC standards.

“These action plans are vetted by the Defense Health Agency, putting us in an excellent position to undergo the real Joint Commission survey, which occurred in July,” Pehrson added.

Mosley explained that in preparation for the survey, the Quality Directorate sent out messaging to all Walter Reed staff on what to expect and developed a comprehensive Survey Readiness Guide covering common findings and compliance topics.

“There was also strong communication from directorate leadership to all hospital departments,” Pehrson added. Staff was ready from the first day to collaborate with surveyors by explaining our processes and policies. They were also prepared to quickly corrected any survey observations and developed strong action plans,” she added.

The Quality Directorate also developed a 95-page pocket guide, distributed to all employees. “This resource served as a refresher on Walter Reed’s knowledge and values, as well as the role of TJC,” Pehrson added.

Pehrson, Mosley and TJC surveyors noted a number of individuals and areas for their contributions to the successful review that became effective July 20, and is customarily valid for up to 36 months, Grubb shared.

“The nurse surveyor remarked it was one of the best data use sessions she has facilitated. Staff demonstrated how robust Continuous Process Improvement is in the MTF [military medical treatment facility]; thanks to Minna Kabteyimer, Dr. Tynesha Papino, and Dr. Brandon Neal,” Mosley shared.

“Dialysis – Department of Medicine and Infection Control Leadership Teams, including Lt. Cmdr. Michelle Bongiorno, Lt. Cmdr. Beth Carter, Cmdr. Amy Frankston, Kelly Andrews and Michelle Wagner were noted for developing ‘a robust, multi-disciplinary, and exceptionally prompt response to correct all survey findings, identify and resolve root causes, and ensure sustained compliance into the future.’” Pehrson and Mosley shared. Dialysis was also recognized for developing “a tiered approach to ensure communication of positive dialysate cultures across multiple departments and levels of leadership, including close oversight by Infection Prevention and Control. The responses were so thorough that there were no requirements for improvement.”

Alvin Cotson, chief of Accreditation and Compliance at Walter Reed, worked with leaders and representatives across the organization to coordinate a successful survey week and response, ultimately leading to another successful accreditation period,” Mosley added. He also noted the support of Lt. Col. Carlos Barrera and Capt. Daniel Neelon as “integral components of the A and C team.”

“The Sterile Processing Department (SPD) is the critical heart of the hospital because it’s essential for keeping the hospital running smoothly and ensuring patient safety by cleaning, disinfecting, and sterilizing medical equipment,” Mosley explained. The health care consulting team that came to Walter Reed for the mock survey prior to TJC noted 10 medium- to high-risk requirements for improvement.

“Working in the SPD environment is stressful,” Mosley added. “The SPD staff’s attention to detail and hard work with the mock survey’s recommendations for corrective actions and sustainment plans, and engagement with continuous survey readiness was showcased in the JC survey, which resulted in zero requirements for improvement.”

Cmdr. Robert Cuento of the Directorate of Surgery “consistently had comprehensive and prompt responses to all mock survey findings in surgical areas, resulting in minimal observations in the Main Operating Rooms – a total of one, which was promptly addressed via re-training staff members on the appropriate policy,” Mosley shared. One of the surveyors noted how well-run the Main Operating Rooms were and stated that if ever they required surgery, they would want to have their procedure performed in the Walter Reed Operating Rooms,” Mosley added.

“The Department of Education, Training and Research, Cmdr. Latarya Gulley and Dr. Clifton Yu), in response to survey observations, collaborated with representatives across the organization to strengthen compliance with competency requirements down to the department level,” Pehrson stated.

“As a health care accreditor, The Joint Commission works with health care organizations across care settings to inspire safer and higher quality of care that is more equitable and compassionate,” Grubbs added. “Through collaborating on innovative solutions and evidence-based resources and tools, TJC helps drive improvement while maintaining accountability through our leading survey methods and standards. We commend Walter Reed for its commitment to advance safety, quality, equity and compassion for all patients.”