The Joint Commission Certified Total Joint Program

Written by Stan Dysart, M.D., M.B.A., and Stephen Kim, M.D., co-chairs of the Total Joint Program at WellStar Kennestone Hospital 

No one needed to tell Jerry Niemeyer about the pain and disability associated with knee arthritis. An active individual, Jerry’s knee pain had progressed to the point that by the time he finished a round of golf, he could hardly get out of the cart.

Jerry had joined one of the 46 million Americans affected by arthritis. That number is expected to grow to at least 67 million by 2030. The number of individuals undergoing total hip or knee arthroplasty is expected to skyrocket as well.

The arthroplasty experience at WellStar Kennestone Hospital has mirrored this nationwide trend and necessitated the creation of a comprehensive Total Joint Replacement Program.

WellStar Paulding Hospital Awarded Certification from the Joint Commission

Four WellStar Hospitals Now Certified in Joint Surgery

WellStar Paulding Hospital has earned The Joint Commission’s Gold Seal of Approval™ for its Knee and Hip Joint Surgery Program by demonstrating compliance with The Joint Commission’s national standards for health care quality and safety in disease-specific care. The certification award recognizes WellStar Paulding’s dedication to continuous compliance with The Joint Commission’s state-of-the- art standards.

The designation now means all WellStar hospitals offering knee and hip joint surgery, including WellStar Paulding, WellStar Kennestone, WellStar Cobb and WellStar Douglas, are now certified in joint surgery by the Joint Commission.

WellStar Paulding underwent a rigorous on-site survey in late 2011. A team of Joint Commission expert surveyors evaluated the Hip and Knee Program for compliance with standards of care specific to the needs of patients and families, including infection prevention and control, leadership and medication management.

The Joint Commission’s Disease-Specific Care Certification Program, launched in 2002, is designed to evaluate clinical programs across the continuum of care. Certification requirements address three core areas: compliance with consensus-based national standards; effective use of evidence-based clinical practice guidelines to manage and optimize care; and an organized approach to performance measurement and improvement activities.

Physician Tips When Speaking with Surveyors

Below is a list of tips when speaking with surveyors:

• Prepare for the upcoming survey by structuring your documentation to meet quality standards; sign, date and time all medical record entries.

• Be aware of service line activities, goals and accomplishments.

• Be positive and proud of what you do to take care of your patients.

• Emphasize world-class healthcare through physician to patient communication, physician to physician communications, and multidisciplinary rounding.

• If asked to participate in an interview with the surveyor, relax. Accreditation will be with each surveyor for staff support.

• If you do not understand the question, ask for clarification before answering.

• Only answer what is asked – do not volunteer information.

• Be honest – if you do not know the answer, do not guess.  Explain how you would find out – physician leadership, nurse manager and accreditation support.

• The surveyor should not request documents from you. Accreditation will provide all documentation to the surveyor(s).

• Be assertive, but do not argue with the surveyor.

The Joint Commission - Informed Discussion and Informed Consent

Informed consent is not merely a signed document. It is a process that considers patient needs and preference, compliance with laws and regulations, and patient education. WellStar physicians should always strive to engage the patient in discussions regarding their health, care plan and treatment. By utilizing the informed consent process, we can help patients make informed decisions regarding their care, including allowing the patient to refuse treatment or revoke consent.

Accreditation Readiness - The Use of Restraints

The Joint Commission Accreditation is required for a hospital to see federally-funded patients. Although The Joint Commission typically conducts surveys every three years, they can appear at any time. Our last survey was conducted more than a year ago.