Ventura County Medical Center Accreditation

The JC’s last full survey of VCMC was in May, 2014. The Accreditation Report considered Physical Environment, Patient Safety, and Patient Care. VCMC received full accreditation for three years, the maximum period allowed. There were four QPR reports for Patient Safety and Patient Care, the last in July, 2016.  Examples of Physical Environment Focus Areas o “Maintaining Fire Safety equipment” o “Management of risks associated with its utility systems” o “Hospital maintains the integrity of the means of egress”  Examples of Patient Safety Goals o “Improve the accuracy of patient identification” o “Improve the safety using medication” o “Reduce the risk of health infections”  Examples of Patient Care Domains o “Heart Failure Care” o “Pneumonia Care” o “Stroke Care” (Ref-06)

The JC report of May, 2014 identified 11 issues regarding Physical Environment. At an unscheduled follow up survey in September, 2014, all issues were resolved.

Of the 17 distinct indicators for Patient Safety, all national and state norms were met in the four QPRs. (Ref-06)

The JC evaluated the VCMC on 10 different Domains for Patient Care, several on more than one occasion. Within these domains there were 94 separate clinical indicators such as timing of medications, appropriate use of laboratory tests, and discharge instructions. There were a total of 118 indicators evaluated in the four QPRs, some on multiple occasions. (Ref- 06) VCMC Accreditation 3

The JC grades Patient Care performance as: Best Possible results, Above the Target range/value, Similar to the Target range/value, and Below the Target range/value. The average for the VCMC based on all four reports were: Result Indicators Percentage Best Possible 60 50.8% Above Target 19 16.2% Similar Target 34 28.8% Below Target 5 4.2% (Ref-06)

The NSQIP is designed to stimulate and measure improvement in quality of care over a period of time. The report on VCMC tracked an average of 92 Quality indicators from January, 2011 through December, 2015. The Quality indicators were rated Exemplary, As Expected, and Need Improvement. The results from the full initial report and the most recent report were as follows: Ratings 01/11-12/11 01/15-12/15 Exemplary 0% 1% As Expected 83% 97% Need Improvement 17% 2% (Ref-03)

VCMC was awarded the Stroke Gold Plus Quality Achievement Award from the American Heart Association/American Stroke Association in 2016. This award recognized VCMC for two or more consecutive years of 85% or higher adherence on all applicable achievement measures and at least 75% or higher adherence with five or more select quality measures in stroke care. (Ref-04)

VCMC was surveyed in June, 2015 by the MBSAQIP in partnership with the American Society for Metabolic and Bariatric Surgery (ASMBS). VCMC achieved a Comprehensive Center accreditation for the maximum period allowed, three years. The MBSAQIP accreditation acknowledges VCMC’s commitment to providing and supporting quality improvement and patient safety for metabolic and bariatric surgery patients. (Ref-05) 4 VCMC Accreditation Conclusions C-01. The VCMC is performing very well as documented in the reports of the required assessments by the JC. (FA-02, FA-03, FA-05) C-02. In pursuit of improvement in quality of care, the VCMC has voluntarily sought and received additional accreditation by three nationally recognized organizations. Surveys by these organizations document consistent improvement in the quality of patient care. (FA-07, FA-08) Responses Responses Required From: None Responses Requested From: None Commendations  The Grand Jury commends VCMC for its record of performance as documented in accreditation surveys.  The Grand Jury also commends VCMC for seeking accreditation beyond what is required, and for its dedication to improvement in the quality of patient care. VCMC Accreditation 5 References Ref-01. Ventura County Health Care Agency 2015 Annual Report http://vcportal.ventura.org/VCHCA/pdf/AnnualReport_2-24-16.pdf (accessed February 9, 2017) Ref-02. The Joint Commission website https://www.jointcommission.org/ (accessed February 9, 2017) Ref-03. American College of Surgeons-National Surgical Quality Improvement Program https://www.facs.org/quality-programs/acs-nsqip (accessed February 9, 2017) Ref-04. American Heart Association/American Stroke Association, Get With The Guidelines-Stroke Gold Plus Quality Achievement Award http://www.heart.org/HEARTORG/Professional/GetWithTheGuidelines/G etWithTheGuidelines-Stroke/Recognition-from-Get-With-The-Guidelines- Stroke_UCM_308034_Article.jsp#.WJzIV00zWUm (accessed February 9, 2017) Ref-05. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program https://www.facs.org/quality-programs/mbsaqip (accessed February 9, 2017) Ref-06. The Joint Commission, Accreditation Quality Report, 5/29/2014, 9/18/2014, 7/14/2015, 7/18/2016 for the Ventura Medical Center https://www.qualitycheck.org/accreditation-history/?bsnId=10178 (accessed February 9, 2017) 6 VCMC Accreditation Glossary TERM DEFINITION ACS American College of Surgeons ASMBS American Society for Metabolic and Bariatric Surgery CMS Federal Center for Medicare and Medicaid Services Disproportionate share Hospital receiving additional Federal funds for hospital treatment of a disproportionate share of uninsured patients Grand Jury 2016-2017 Ventura County Grand Jury MBSAQIP Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program of the ACS NSQUIP National Surgical Quality Improvement Program of the ACS QPR Quality Performance Report JC The Joint Commission, formerly known as the Joint Commission for the Accreditation of Health Care Organizations Safety net hospital Hospital providing care for a large number of low-income or uninsured patients VCHCA Ventura County Health Care Agency VCMC Ventura County Medical Center, a hospital. When used by the JC and in Annual Reports of the VCHCA, VCMC includes Santa Paula hospital and related outpatient clinics VCMC Accreditation 7 8 VCMC Accreditation VCMC Accreditation 9 This page intentionally blank 10 VCMC Accreditation VCMC Accreditation 11