Cortland Regional Medical Center is taking steps to improve policy and structural aspects of the hospital after a leading international accreditation agency issued a preliminary denial of accreditation.
The Joint Commission International, a private accreditor that identifies, measures and shares best practices in quality and patient safety, surveyed the hospital in July and, according to its website, found a condition at the time of the survey that poses a threat to patients or other individuals.
The commission keeps it accreditation reports confidential.
Molly Lane, marketing communications manager for the Cortland hospital, said no patient has been harmed at the facility. She added the safety and quality of care to the medical center’s patients has continued without interruption.
The accreditation preliminary denial also has not had an effect on the pending affiliation between the Cortland hospital and Guthrie Medical Group of Sayre, Pa., Guthrie officials said.
“During the week of July 16, surveyors representing The Joint Commission on behalf of the Centers for Medicare and Medicaid Services, conducted a review at Cortland Regional Medical Center,” said Lane in a written statement. “During the review, CRMC was made aware of opportunities to improve patient safety.”
The opportunities for improvement identified in the commission’s initial survey included policy and structural updates, Lane said. Fixtures were upgraded, standard procedures were updated and staff completed additional training. Further detail on what was specifically upgraded was not provided.
On Aug. 10, the commission returned to the hospital for a follow-up survey, she said.
“We received the verbal update from The Joint Commission that the improvements that were implemented were approved,” Lane said in the statement.
The medical center plans to continue working with the commission to further address performance issues.
The medical center’s accreditation preliminary denial status on the commission’s website will remain until all corrections are complete, Lane said.
Accreditation costs, and pays off
Hospitals pay to have the commissions do the survey for accreditation, said Diana Culbertson, senior information specialist for the American Hospital Association. The price can be hefty, she added, but did not know the exact cost.
Accreditation can help hospitals meet state requirements, borrow money from banks and be certified in the Medicare program, Culbertson said. “It gives assurance a hospital is meeting standards of care.”
Some hospitals don’t go through the process, she added.
However, if a hospital cannot meet the Medicare certification because it is not accredited, that would be a big issue, Culbertson said. It wouldn’t be able to treat Medicare patients. Medicare could recognize accreditation from another agency, too, she said.
The medical center’s operating revenue is $97.2 million. Fifty-six percent of that comes from Medicare and Medicaid.
Success against sepsis
A recent state report –– which covered the 12 months through March 31 –– shows the Cortland Regional Medical Center’s sepsis –– a lifethreatening complication of an infection –– survival rate was 89 percent, compared to the state average survival rate of 75.6 percent. Also the center’s septic shock patient mortality rate was 11 percent, while the hospital mortality rate statewide was 24.4 percent.
Since the commission began accrediting hospitals in the 1960s, the medical center has been a part of the process and has maintained its accreditation, Lane wrote. She called the commission’s accreditation “the gold standard in global health care.”
“We are surveyed every three years,” Lane wrote. “Accreditation by The Joint Commission is the hospital equivalent of the Good Housekeeping Seal of Approval. It demonstrates our organization’s commitment to achieving a higher level of patient safety and quality of care.”
She said the medical center remains focused on addressing the remaining issues identified by the commission as quickly as possible.
Details of the planned affiliation, announced last year, between Cortland Regional Medical Center and Guthrie Medical Group remain in development with the finalization of the agreement projected in 2019, a Guthrie representative said.
“Health care organizations such as Cortland Regional Medical Center and Guthrie seek the accreditation of The Joint Commission to assess their performance against established standards and to identify opportunities for continuous improvement,” wrote Paul VerValin, executive vice president and chief operating officer for Guthrie.
“We are confident in the leadership of CRMC and its dedication to providing high quality care to the community it serves.”
The affiliation, announced in September, would bring many benefits to the medical center, which with 740 employees is the largest private employer in the county:
• $41 million in infrastructure and electronic records upgrades over five years.
• No cuts in services for at least 10 years, without both organizations’ approval.
• Local control of the 162-bed hospital and 80-bed nursing facility.
• Access to some of the most advanced health care in the world through an affiliation with the Mayo Clinic.