Joint Commission survey is over, and I hear we scored pretty high with no Type 1 findings. This is a good thing. So we’re good for another 3 years. Excellent.
Laying Low
Joint Commission is cruising through the hospital this week. Time for me to lay low and keep a low profile. Not that much of what I do will draw their attention, but the less of it I have to deal with, the better.
Solving problems
Ever have one of those problems where the more you dig into it to find a solution, the more complicated it becomes?
A couple of days ago, I started digging into a problem we were having with one of our computed radiography (CR) readers. Techs were complaining that they were starting to have to use much higher x-ray techniques than normal to get properly exposed images. So, I head over, and run some quick checks with some of my test objects, and narrow it down to the CR reader. Sure enough, the reader in question was producing a lower exposure index (a number that’s related to how much radiation the CR plate was exposed to) than an older CR reader next to it.
The next day, I head over there with some more test objects to get some more quantitative data, and confirmed just how much lower the CR reader was responding.
Today, I decided I had better check our other CR readers. They were all relatively new (installed April 2003), and I had data for some of them when they were first installed. The testing is something I usually try to do on a monthly basis, but the summer was a pretty busy one, so I hadn’t been able to get to doing my regular tests on them. Much to my surprise, I found all of the other CR readers producing lower exposure index values too. And to make it worse, they were all lower by the same amount. Each of the CR readers runs a set of diagnostics periodically on various systems, which is very useful. A quick check of those results didn’t reveal anything significantly wrong that I thought would cause the problem though. So now, instead of trying to figure out what the problem with one unit is, I have to figure out what could be causing the same problem on 5 different units. Could it be the laser assembly? The light guide? A photomultiplier tube?
At first my guess was the laser starting to fail. But how does it happen to 5 different units by the same amount? A bad batch of lasers perhaps? Who knows. The more I dig into it, the more perplexing the problem becomes.
Joint Commission Jitters
In a few short weeks, JCAHO surveyors will be descending on our institution to check on how well we do things. This will be the second JCAHO accreditation survey I’ve been through here. Prior to the first one, there was much scurrying and commotion as everyone tried to get ready for the survey. This time around, most of the scurrying and commotion was spread out over the past year and a half. Still, with a few weeks to go, there’s more and more activity to get everyone ready.
JCAHO accreditation is a big deal for hospitals. Being accredited and getting a good score on surveys is a good marketing tool, and shows the institution follows a tight set of standards and practices. Plus it’s also required to qualifiy for Medicare/Medicaid funding.
Our survey is scheduled for Nov 17. As far as my little portion of the survey, I don’t expect to see much activity. My records are in pretty good shape (much better than when I first started here), and I can pretty much account for everything that I’m responsible for. Since I’m not directly involved with anything patient care related, I will be surprised if surveyors stop by to ask me for anything at all.
Bring it on, JCAHO…
Productive day
After being busy with other things the past couple of months, time for me to start whittling down the list of x-ray equipment I need to get tested by the end of the year. Spend a couple of months doing pretty much nothing except testing, then take the next couple of months to work on other projects. I do this maybe 4 or 5 times throughout the year to break up the monotony of doing all the annual surveys. With all the side projects I keep coming up for me to do, I find this works out better for me instead of spacing out all the testing evenly through the year. The breaks between equipment testing give me some time to work on projects and research. Makes getting back to testing easier too, after taking a break.