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45 Years of Ambulatory Care Accreditation: Three Personal Stories


Tempered by a recognition of the impact COVID-19 has had on our many health care partners and customers during the Ambulatory Care Program’s 45th year, we’ll be sharing stories from our customers, surveyors and internal staff in AmBuzz over the months ahead. 

Pandemic Preparation at Ochsner Urgent Care & Occupational Health
Our first story comes from ambulatory care customer Gina Mmahat, clinical director of Ochsner Urgent Care & Occupational Health, Louisiana – accredited since 2009.

Joint Commission accreditation has proven to be a vital asset for Ochsner Urgent Care during the coronavirus pandemic. If there’s any one area The Joint Commission had the strongest and most positive impact during COVID-19, it was infection prevention and control (IC). Thanks to constant attention to IC-related issues at our 16 urgent care locations across the New Orleans metro area, we were more than prepared for the onslaught of COVID-19. For example:

  • Thanks to early planning, we had plenty of Personal Protective Equipment (PPE) and staff were trained on appropriate PPE donning and doffing
  • We quickly implemented social distancing protocols at all locations using 6-foot distancing signs, screening stations and signage for cleaning and sterilization between patients 
  • Staff were thoroughly trained to test and triage potential COVID-19 patients

Without these ongoing efforts to maintain accreditation, Ochsner Urgent Care may have scrambled to address the coronavirus. Like most of our health care colleagues across the country, we’re anxious to put COVID-19 behind us, but our Joint Commission accreditation continues to bring us an extra level of assurance as we move forward. 

Impact on Infection Control
Ambulatory Care Program surveyor Joe Flannery has represented The Joint Commission for over 26 years and has shared many patient safety and performance improvement insights with our customers during his accreditation survey journeys. Flannery’s thoughts from where the rubber-hits-the-ambulatory-road: 

I’ve always believed my job is to leave our customers in a better place than when I walked in their door. That’s how I approach every survey, whether it’s a first-time survey or re-survey. I’ve visited an array of health care services, from community health centers, to imaging centers, to surgery centers. I’ve also crisscrossed the world surveying our Department of Defense customers overseas. For me, COVID-19 has really highlighted the value of The Joint Commission’s focus on IC. 

There are a few IC stories from my time as an ambulatory surveyor that make my point.

  • Despite a community health center’s confidence its autoclave was in perfect working order, four of five tests conducted on sterilization equipment failed. After a walk-though with autoclaving process staff, it was apparent the equipment maintenance process had broken down. In collaboration with the health center’s IC team, we found a missing checkpoint and helped remedy the problem.
  • Similarly, a survey conducted at a sleep center offering home sleep testing (HST) revealed it was following improper IC cleaning protocols for equipment. Though initially surprised to discover the error, staff was pleased to realize a few small changes in the cleaning processes would ensure safe and infection-free equipment for patients. 
  • My most impactful experience took place within the first few minutes of beginning my environment of care (EC) tour at an ambulatory surgery center (ASC). As I made my way around the exterior of the ASC with the administrator, I noticed the odor of gas. When I asked the administrator if he also noticed the odor, he said no. As we continued to walk the ASC perimeter, the odor became stronger and I insisted the administrator – despite his misgivings – call the gas company. When the gas company representative arrived and checked for leaks, he confirmed that gas was ”pooling” under the ASC. He called the local fire department and ordered the ASC be immediately cleared of staff and patients and closed until the gas leak was stopped.
    These are just three stories from my accreditation experience “notebook” that tell me The Joint Commission has made a positive difference… and that I’ve left our customers in a better place than when I first walked in their door.

Behind the Scenes in Survey Scheduling
Ben Pickett has worked for over 34 years in a variety of positions at The Joint Commission. During the last 15 of those 34 years, Ben has served as primary “scheduler” for the Ambulatory Care Program. In this role, Ben has been the key behind-the-scenes player in the multi-faceted operational machine that delivers our surveyor to your organization’s front door. 

I really enjoy my job as scheduler for the Ambulatory Care Program. I’ve held several other jobs at The Joint Commission, but once I got the hang of what it takes to be a survey scheduler, I could never see myself doing anything else. I take the information gleaned from an application after it’s been processed by your account executive and match the right surveyor clinical expertise (we have a roster of approximately 50 nurse, physician and administrator surveyors dedicated to the Ambulatory Care Program) with the right organization. Our ambulatory care surveyors are a wonderful group of professional people and come from a variety of health care environments: urban, rural, surgery, medical, military and academia. Best of all our surveyors bring their diverse, real-world experiences to organizations during the on-site review. 

Staff safety is our number one priority. Managing ready date timeframes, surveyor availability and adding COVID-19 into the mix can get pretty complicated. Whether it’s your first initial deemed Medicare or non-deemed survey or it’s been happening for decades,  I work closely with your account executive to schedule your survey based on your ready date – scheduling as close as possible to the date chosen and determining which regions are safe to survey during COVID-19. 

Thank you to you, our valued customers, for continuing to trust The Joint Commission. And, thank you to our ambulatory care team, surveyors and scheduling department for working closely with ambulatory organizations to improve patient safety and quality of care.