AGANA HEIGHTS (March 21, 2019) - USNH Guam listens to surveyors during the MEDIG and TJC out brief. (U.S. Navy photo by USNH Guam Public Affairs)
AGANA HEIGHTS (March 21, 2019) - USNH Guam listens to surveyors during the MEDIG and TJC out brief. (U.S. Navy photo by USNH Guam Public Affairs)

Medical Inspector General and the Joint Commission conduct their triennial visit to U.S. Naval Hospital Guam

by Jaciyn Matanane
Public Affairs Officer, U.S. Naval Hospital Guam

AGANA HEIGHTS, Guam (April 9, 2019) – The Bureau of Medicine and Surgery, Medical Inspector General (MEDIG) and the Joint Commission (TJC) visited U.S. Naval Hospital Guam from March 18 to March 21, 2019. The purpose of the MEDIG visit was to ensure compliance with higher authority policies in the hospital’s day-to-day operations, processes, procedures, programs, and activities. MEDIG communicates discrepancies found in Military Treatment Facilities and provides feedback on areas identified for improvement. TJC administers accreditation for hospitals and other healthcare organizations based on compliance with performance standards.

The onsite survey was a four-day evaluation that focused on infection control, medication safety, leadership, training and competence, performance improvement and patient care. Surveyors assessed over 65 programs throughout the hospital that included primary care services, deployment health assessment, infection prevention and financial reporting.

“I think we did an amazing job as the world of Inspector General involves endurance”, said MEDIG Hotline Coordinator and Department Head, Occupational Therapy, Lieutenant Commander Elizabeth Corales. “The program managers and hospital MEDIG team have been working towards this point since our last inspection three years ago. Findings from that inspection were corrected and we continue to evolve programs to meet and exceed the latest in program guidance.”

USNH Guam received their survey notice early February 2019. After receiving notification, the command worked together as a team to prepare, from leadership, senior enlisted, civilians and contractors, to the most junior Sailor and housekeeping staff.

“The command climate was pretty stressful leading up to the survey”, said Quality Management Department Head and USNH Guam Joint Commission Officer, Commander Christopher Jack. “It was a one hundred percent effort on everyone’s part to really make our hospital shine the best that we can. Overall, I think that the staff appreciated the extra work that everyone had invested in once the surveyors got on board and started to interact with them. The staff did an outstanding job.”

Over 40 top performers were commended for their excellent work. Many departments were given a “bravo zulu” such as the pharmacy department for medication management and the maternal, child, infant nursing department, intensive care unit and multi-service unit for having a robust simulation process. The uniform business office was commended for its diligence in reducing aged accounts receivable from one million to zero in less than six months. The materials management department staff were commended for their outstanding management and execution of logistics operations, and indicated that USNH Guam had the best inventory management program reviewed to date by MEDIG. USNH Guam shined in other areas such as the high level disinfection process of endoscopes, medication error reduction, environment of care services and cleanliness.

As a high reliability organization, USNH Guam provides safe, high quality care every day. USNH Guam welcomes these survey visits every three years as an opportunity to improve and to provide better, safer care.

“I think the biggest take-away is that it shouldn’t be about the survey, it should be about the next patient we are caring for”, said Cdr. Jack. “The reason we do what is right is to prevent patient harm and to give the best quality care possible. It’s a known fact that it is human nature to stop seeing the problems and issues if you have been at an organization long enough. Having someone from the outside come in to look is great, because they see the things we have stopped seeing. They can wake us up to these issues so we can address them and keep on the path to High Reliability”.

The official report and results of the survey will not be released until thirty days post-inspection.

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