Virginia Mason Medical Center in Seattle was found out of compliance in nearly 30 areas during a surprise visit in May by the Joint Commission, a nonprofit group that accredits hospitals across the nation.
Seattle’s Virginia Mason Medical Center has been denied full accreditation by the Joint Commission after the hospital failed to meet nearly 30 standards during a surprise review in May.
The unannounced visit by the nonprofit group that inspects 21,000 hospitals and programs in the U.S. found that Virginia Mason was out of compliance in 29 areas ranging from conducting fire drills and reducing risk of infection from medical equipment and devices to providing an environment with no risk of “immediate threat to life.”
Virginia Mason officials declined requests for interviews Tuesday, but said in a statement that the hospital respects the Joint Commission’s opinions and is working to fix the problems that resulted in “contingent accreditation” status.
Out of compliance
Here are 10 of the 29 areas where Virginia Mason Medical Center failed to meet Joint Commission standards during a May visit. To see the full list, visit the Quality Check web portal.
• Care, treatment and services provided through contractual agreement are provided safely and effectively.
• Resuscitation services are available throughout the hospital.
• The hospital conducts fire drills.
• The hospital establishes and maintains a safe, functional environment.
• The hospital has an infection prevention and control plan.
• The hospital inspects, tests and maintains medical equipment.
• The hospital provides care, treatment and services as ordered or prescribed, and in accordance with law and regulation.
• The hospital provides care, treatment, services and an environment that pose no risk of an “immediate threat to health or safety, also known as “immediate threat to life,” or ITL situation.
• The hospital reduces the risk of infections associated with medical equipment, devices and supplies.
• The hospital safely stores medications.
“Our teams are working through items the agency has focused on and we are confident we will address them to the Joint Commission’s satisfaction in the coming weeks,” the statement said.
At the time of the survey May 20, commission members concluded that a condition existed “that posed a threat to patients or other individuals served,” an agency document showed. The hospital was given a preliminary denial of accreditation, a rating that was changed to conditional accreditation June 1, after a follow-up visit.
The document didn’t provide details of the threatening condition. But the initial visit triggered an announcement last week that Virginia Mason is notifying 650 patients dating back to 2011 that the hospital failed to properly screen clients for hepatitis B infections at an on-site kidney dialysis center.
The potential risk of infection is quite low, officials with the hospital and Public Health – Seattle & King County said.
The list of deficiencies cited by the Joint Commission includes several crucial areas in which Virginia Mason didn’t meet standards, including a requirement that the hospital “inspects, tests and maintains medical equipment.”
That notice comes more than a year after revelations that 39 people were sickened, including 18 who died, during an outbreak of multidrug-resistant infections tied to contaminated medical scopes at Virginia Mason between 2012 and 2014.
Gale Robinette, a hospital spokesman, said that there are several elements within each of the Joint Commission standards, and if a facility misses any of them, it is considered out of compliance.
“Let’s take an easy one,” said Robinette. “We do have fire drills. But in the view of the Joint Commission surveyor, there should be more variability in the scheduling of our drills.”
Robinette declined to describe how the hospital failed to meet the remaining standards.
Other Seattle-area hospitals are fully accredited, a review of the Joint Commission’s Quality Check website showed. That includes the University of Washington Medical Center, accredited in June 2013; the Veterans Affairs Puget Sound Health Care System, accredited in October 2013; Swedish Medical Center, accredited in October 2014; Harborview Medical Center, accredited in November 2014; EvergreenHealth Medical Center, accredited in June 2015; and Overlake Medical Center, accredited in January 2016.
The Joint Commission conducts surveys every 18 months to three years, a spokeswoman said. The organization is the nation’s oldest and largest accrediting body in health care.
At Virginia Mason, an unannounced follow-up survey will be conducted within three months to ensure that the deficiencies identified in the original report have been corrected, a Joint Commission document indicated.