UNHS passes Joint Commission survey to retain accreditation

19Utah Navajo Health System, Inc. has been serving the health care needs of San Juan County residents for the past sixteen years, and for nearly a decade UNHS has been accredited by the Joint Commission.

UNHS passed its fourth Joint Commission survey in late March and received high praise from surveyors who examined three of the four UNHS Community Health Centers. The two surveyors spent four days going over every aspect of the UNHS Patient Centered Medical Home and Ambulatory Care operations at the Blanding Family Practice, Montezuma Creek and Monument Valley Community Health Centers. According to UNHS CEO Michael Jensen, the surveyors were extremely impressed with the UNHS staff, and the operations of all three facilities surveyed.

“It was awesome. We were prepared. We did things differently this time in the way we prepared and it showed. It’s nice to see or efforts actually pay off,” Jensen said. “We were accredited for both Patient Centered Medical Home and Ambulatory Care, but the encouraging thing is that we were not cited for anything we were cited on three years ago. The surveyors just found some small minor things that will allow us to improve and do things better in the future.”

Jensen said much of the credit for the successful Joint Commission survey belongs to UNHS staff members Donna Jensen and Sylvia Lopez. The pair spent the last couple of years working to make sure UNHS was ready for, and able to pass, the latest Joint Commission survey. They worked tirelessly at every UNHS site, educating, updating and preparing providers and staff to meet the grueling demands of Joint Commission standards.

“I would like to acknowledge how well everyone worked as a team. UNHS staff has worked hard and will continue to work hard to maintain the high standards of Joint Commission,” Donna Jensen said. “We have processes in place.  We have a team that surveys every clinic quarterly and educates the staff after each visit. The members of this team represent all key areas of compliance.  Ongoing education with all staff is vital and we track compliance with various new software products. UNHS has an amazing staff. They have been wonderful to work with.”

Michael Jensen said he was impressed with how prepared for the survey each department was. He said each department had their areas ready with all documentation in place. Things looked good and everyone did what they needed to do to be prepared. Jensen added that the surveyors were very complimentary about how welcoming the UNHS staff was to them. The surveyors also complimented the staff on their knowledgeable and how willing staff was to accept change.

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Physical Therapist Assistant Alon Pugh and UNHS CEO Michael Jensen (R) chat with Joint Commission Surveyors during the recent Joint Commission survey. UNHS passed the survey and received accreditation. Photo Bryan Mose

“The surveyors made suggestions about how to improve and do better, and they noticed no push back from staff. Instead, the staff was open to learning a better way,” he said. “It was interesting to hear the surveyors say, at a lot of places they go they can feel the walls being put up. If you want to do bad on a survey why not be rude to the surveyors? It’s amazing that some places have that mind set. I think training is paying off.”

Jensen added that now the challenge for UNHS, after working so hard to get accredited for the fourth time, is to make sure they maintain their standards and for the next three years not let their guard down or slip. They need to maintain the standards that have helped them achieve Joint Commission Accreditation and become the biggest employer in the county with roughly 290 employees.

Sylvia Lopez addressed this issue. She said, “Our goal is to maintain the standards we have reached to meet this Joint Commission survey. The challenge will be keeping up with the continuous changes in health care and Joint Commission standards. We will approach this by doing the quarterly mock surveys at each site and continue with having joint meetings among different departments, and keeping everyone informed of what we see needs to be changed or improved.

“We strongly encourage all employees to work with their department leader to do Continuous Quality Improvements to make changes,” she added. “The staff of UNHS is awesome to work with. Their willingness to work hard and keep in compliance helps us a great deal.  Communication is going to be key to our success.  We look forward to delivering the best and safest health care in the area. I would like to thank all of our employees at UNHS for a job well done.”

The Joint Commission (JC) is an independent, not-for-profit organization charged with establishing standards and accrediting health care organizations. The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in healthcare.

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