PDC Successfully Completes 2016 Joint Commission Review

Duke PDC

The DHIP has successfully completed its latest review by The Joint Commission, the gold standard in health care quality and safety accreditation. Based on its final report, the DHIP expects to receive its ambulatory care accreditation for another three years. 

In September, surveyors visited 40 DHIP clinics to assess system-wide quality, safety, policies, functions, leadership and overall performance using more than 1,000 standards.  The rigorous survey is intended to identify areas of improvement, and to recognize and educate staff and providers on best practices in care delivery.

Surveyors identified a number of exceptional performance areas, including:

  • The use of data in management, goal setting and performance improvement
  • Development of a formal structure to monitor and improve patient experience
  • Deployment and use of Epic and MyChart
  • Competency training of staff, including point of care training, quality checks and basic life support
  • Rapid and sustained performance improvement throughout the organization and clinics
  • Focus on system-wide learning
  • Commitment to the identification and growth of staff, management and providers
  • Leadership, structure, processes and outcomes

The surveyors described the DHIP as having “a bias for action” for its agility and emphasis on addressing problems when they arise. 

Specifically, the surveyors identified as national best practices the DHIP’s provider onboarding process, performance improvement and ambulatory falls prevention programs.

In addition to The Joint Commission accreditation, the DHIP also sought Primary Care Medical Home (PCMH) certification for the first time.  PCMH aims to transform how primary care is organized and delivered through comprehensive, patient-centered, coordinated and accessible services.  During the review of Duke Signature Care, surveyors identified no findings and recognized the clinic “as a leader in PCMH.”  The report paves the way for expansion and implementation of the PCMH model in other DHIP primary care locations.

Areas of focused improvement for the DHIP that were identified by the survey include:

  • Medication management
  • Infection control
  • Assignment of access rights
  • Reliance on Duke University Health System for functions, such as human resources and infection control

The DHIP is developing action plans to address each of these areas and will begin implementing the plans immediately.

These outstanding results are a testament to the commitment and hard work of our staff and providers. I'd like to personally thank all of our DHIP members and clinic staff, especially Dr. John Paat, Kim Denty, Martha Dorroh, Camille Grant, the DHIP Joint Commission Liaison and Surveyor Teams for their outstanding leadership and preparation.

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The Joint Commission evaluates, accredits and certifies more than 20,500 health care organizations and programs in the United States. An independent, not-for-profit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Learn more at www.jointcommission.org