Documents show one of the primary reasons a standards group temporarily denied accreditation to SMMC

The Joint Commission, a health care standards group, has endorsed St. Michael Medical Center after it handed down a preliminary denial of accreditation to the hospital in September.

The commission’s website now lists the facility as accredited, effective Dec. 15, 2022, noting an on-site survey on the same date.

Little information was released publicly about what prompted the group to deny the facility’s accreditation in the fall; the commission’s public-facing website later identified 39 general areas where “performance issues” had been found. Since then, records obtained by the Kitsap Sun have identified a specific area of immediate concern the group had: the facility’s care for suicidal patients.

The Kitsap Sun requested an interview with hospital president Chad Melton for this story, but a Virginia Mason Franciscan Health spokeswoman would not make him available for comment. A statement provided by VMFH spokeswoman Susan Callahan on behalf of the hospital noted that the commission had evaluated compliance with more than 250 accreditation standards and found “opportunities for improvement” in 39 areas. The statement said that it’s typical for the commission to find multiple such areas and said that many of the commission’s findings were “low risk.”

“We immediately implemented an action plan to address these findings, which was validated by TJC,” the statement said. “Our improved practices were sustained throughout multiple return visits from TJC.”

From September:Care standards group gives St. Michael Medical Center preliminary accreditation denial

When the commission first handed down the preliminary denial, only a general description of an area of concern was available: “Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.”

In an interview in September, Melton offered few specifics about what the commission had found but said no patient harm was identified in its assessment and that the commission found “process improvement things we could have done better.”

Department of Health records obtained by the Kitsap Sun through the state’s Public Records Act give insight on the commission's findings related to the facility’s care for suicidal patients and the hospital's response.

In an email to DOH officials on Sept. 2, the Joint Commission’s Mary Wei, senior associate director for state relations, reported that the group had declared there was an “immediate threat to health or safety” at St. Michael Medical Center following a survey from Aug. 30 through Sept. 2. The message noted a series of concerns as well as mitigation steps that were being implemented by the facility.

Immediate threat drivers, according to the message: “Patients determined to be at high risk for suicide were not placed on 1:1 continuous observation with the ability to immediately intervene in rooms that contained ligature and other safety risks.” The message noted further: “Patients attempted suicide and were still not placed on continuous observation with the ability to immediately intervene in rooms that contained ligature and other safety risks" and, "No evidence of additional actions taken to protect individuals who attempted suicide while at the organization, including enhanced observation and/or environmental modification, who subsequently attempted suicide again."

Referring to a specific incident, the message noted: “Process to remove non-essential items from the room of a high-risk suicidal patient was not done as evidence by patient having access to needles which he attempted to self-harm with.”

The alert said that, “Leadership did not provide for sufficient staff to perform 1:1 continuous observation for patients determined to be at high risk for suicide” and said there was no evidence leadership analyzed suicide attempts that occurred at the organization in 2020, 2021 and 2022 to improve safety.

The message also noted: “Multiple attempts involved the use of linens; however, the organization had not evaluated the use of linens in the Emergency Department for high-risk suicidal patients; Multiple attempts involved patients who were on video monitoring while in the (Emergency Department) ‘safe’ area, the organization had not evaluated the use of video monitoring for high-risk suicidal patients.”

Asked about the findings related to suicidal patients, VMFH acknowledged in its statement that the commission had found areas of concern “that could put this population of patients at increased risk. We immediately implemented an action plan to enhance our existing processes to comprehensively address their findings. We are committed to maintaining these protocols as part of our standard process moving forward.”

Some of the process improvements related to that patient group, according to the statement:

• Enhanced screening of patients for suicide risk and severity of risk

• Enhanced processes to prevent suicide, including environmental safety sweeps of rooms

• Improved documentation in the medical record for suicide risk patients

• Enhanced discharge planning

Records provided by the DOH include internal emails and documents detailing the response to the commission’s findings. One document from September details various protocols and procedures for staff to follow related to patients with suicidal ideation, including that staff remove patient clothing and belongings and place patients in paper scrubs, use the Columbia Suicide Severity Rating Scale for assessing patients, and document patient conditions and checks and environmental safety.

Said Melton, in the statement provided to the Kitsap Sun: “St. Michael Medical Center received notification from The Joint Commission that the hospital has received an accreditation decision of ‘accredited’. This is a reflection of our ongoing commitment to quality and safety, as well as a lot of hard work by the team. We take any findings for improvement seriously, and are dedicated to ensuring we maintain the highest quality and safety measures for our patients and staff.”

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This article originally appeared on Kitsap Sun: Joint Commission signs off on St. Michael Medical Center accreditation