The Joint Commision

Posted by Sarah Thiel at Thursday, August 05, 2010

My first rotation is at Providence Hospital in Southfield, Michigan for hospital pharmacy administration (nontraditional).

I was full of pre-rotation jitters Sunday night before my first day. I even picked out my outfit and made my lunch the night before - a habit I had left behind in high school! I got a good nights sleep and left Ann Arbor at 6:30am since I had never driven to Southfield before and wanted ample time to arrive.

I successfully maneuvered through morning rush hour traffic and even found a parking spot that was free of charge - which is a novel idea when one gets used to paying everywhere in Ann Arbor for parking.

My preceptor's administrative assistant met me at the employee entrance and showed me the way to the pharmacy department. She showed me around the department and introduced me to many people. My preceptor (the director of pharmacy) wasn't going to be in until Tuesday, so his manager took me under his wing for the day. When he arrived at 8am he had very interesting news for me - The Joint Commission (TJC) had arrived to survey our hospital system.

My tour of the nursing units was on the fly as the manager took me to every department to check all the medication room refrigerators for multi dose vial dating compliance before the surveyors began looking around. TJC now requires all multi dose vials be dated with a "beyond use date" of 28 days after it was opened or punctured (http://www.jointcommission.org/NR/rdonlyres/7DDACC46-9522-4DA6-B7A4-A41F52745A7E/0/jconlineJune910.pdf).

From there we went to "The Command Center" to get the latest scoop on what the surveyors' schedule would be. Here I was introduced to the two nursing directors as well as the Chief Medical Officer (CMO). One really great aspect of this institution is the level of support the Department of Pharmacy receives from nursing, the CMO, and other higher-up executives- and what a difference this support makes to developing and implementing pharmacy services!

I was then introduced to the Team Leader Surveyor and was able to tag along with the entourage of people accompanying her. What you will quickly find out about TJC surveyors is that they know how to get the information they need and that they are very good at their jobs - if there are any discrepancies in policies or procedures they will find it. They ask hundreds of questions and follow up on any issue of possible concern they find. All the employees at the hospital are basically told the same thing for how to interact with the surveyors: 1) Be polite but don't speak unless spoken to, 2) Be clear and concise when answering questions, and most importantly 3) Don't divulge or offer up any information that wasn't explicitly requested.

Having the Joint Commission here for an entire week has been a great way to kick-off my hospital pharmacy administration rotation. I have already attended several debriefing meetings, participated in conference calls regarding pharmacy technologies, presented information to physician and nursing surveyors, gave two summary overviews of the medication management tracer to the pharmacy staff, discussed the ongoing drug shortage issues, and even discussed initiatives to reduce departmental costs while improving patient care!

Now that week one is already close to an end, I am already very comfortable with this hospital and all the staff- everyone here is so friendly!

Who knows whats in store for next week!