"That was almost impossible to do," Winslett said. "We are thrilled."
Joint Commission conducts full, unannounced surveys every 18 to 39 months.
Of Physicians Carraway's 13 improvement areas cited, five involved problems with use of physical restraints, either in the documentation of their use or monitoring the patients in them. Other problems involved complying with hand-washing guidelines, marking the operation site and taking a "time out" just before surgery for verification of the case's specifics.
Winslett said many of the problems involved not keeping records the way Joint Commission requires. Some of the issue was an incorrect interpretation of Joint Commission standards. For example, Physicians Carraway followed the protocol to mark the surgery site and take a pre-operation "time out," Winslett said. But a registered nurse performed those tasks, while the Joint Commission requires a physician to do so, she said.
Winslett said Physicians Carraway was at a disadvantage because the previous hospital operators were cost-cutting consultants who did not hire a group to keep hospital staff up-to-date on standards, buy materials that would have helped or even have a quality officer on staff - things other hospitals do. Physicians Carraway bought Carraway Methodist Medical Center out of bankruptcy in November 2006, after years of various consulting groups running the facility.
"You can't make up for that much neglect in a short time," Winslett said. "I don't feel we weren't giving safe care at all. We were. But we weren't documenting the way Joint Commission wanted us to document."
To trigger a conditional accreditation, a large hospital has to have 13 cited improvement requirements, and 17 or more trigger preliminary denial. Surveyors automatically put a hospital in preliminary denial if they witness an immediate threat to a patient's life, which was not the case at Physicians Carraway.