Westchester Medical Center accreditation issue

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Westchester Medical Center accreditation downgraded

By MELISSA KLEIN

THE JOURNAL NEWS

(Original publication: June 12, 2007)

VALHALLA - Westchester Medical Center's accreditation was lowered after it failed to meet one of its own documentation standards for assessing pain.

The medical center's accreditation is considered provisional, meaning it is not in full compliance with all applicable standards, according to The Joint Commission, the national organization that did the rating.

The hospital has until the end of August to show it is in compliance or it could risk an even further downgrade, said Elizabeth Zhani, a spokeswoman for The Joint Commission.

Kara Bennorth, a medical center spokeswoman, said in a statement that the hospital was now consistently meeting the standard to show that it assessed a patient's pain one hour after treating the pain and documented that assessment.

"It is important to note that this is an issue of documentation and not one of treatment," Bennorth said in the statement.

This is the second time in three surveys from The Joint Commission that the hospital has been downgraded. Hospitals must be properly accredited by organizations such as The Joint Commission to receive reimbursement from the federal Medicaid and Medicare programs. The downgrade is not expected to affect reimbursement, Bennorth said.

The downgrade, which was made April 25, is on The Joint Commission's Web site, but was not made public at either the May or June meetings of the hospital's board of directors. Bennorth said that Michael Israel, the hospital president, had shared the information with board members, sometimes in informal conversation.

The most recent downgrade relates to August, when a Joint Commission team did its regular survey of the hospital. The hospital was accredited with requirements for improvement.

Most hospitals nationwide fall into that category after evaluations. Joint Commission statistics for 2006 show that 95 percent of hospitals had one or more requirements for improvement.

Bennorth said the medical center had 13 requirements for improvement after the August survey.

Zhani said hospitals are required to prove they have corrected whatever deficiencies exist and then follow that up with sustained compliance to what is called a "measure of success." She would not provide details on what the medical center was required to do.

Bennorth said the medical center had three areas in which it had to conduct self-assessments. Those areas were eliminating the use of specific abbreviations, keeping temperature logs for refrigerators and documentation of reassessing pain.

She said the hospital set a "very high standard" to reassess and document pain every hour, 90 percent of the time.

She said the medical center would soon submit evidence to The Joint Commission that it was meeting the standard.

The Joint Commission does not have statistics on the number of hospitals with provisional accreditations. Every other hospital in Westchester, Rockland and Putnam counties has a full accreditation from The Joint Commission, according to the agency's Web site, www.jointcommission.org. The agency, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, posts its assessments of health-care providers at www.qualitycheck.org.

In 2001, the medical center received a conditional accreditation, which is one step below provisional, after a Joint Commission evaluation team caught a medical resident and several nurses altering a patient's chart. Missing information had been added to the chart and backdated. The rating was upgraded later in the year.

The medical center was accredited with requirements for improvement in November 2003, and then given a clean accreditation the following July.

The hospital, as it weathered a financial crisis in recent years, let the accreditation of some of its speciality programs lapse. Its cancer program, for instance, is the only local one not accredited by the American College of Surgeons. The speciality accreditations demonstrate that programs met certain, often rigorous, standards.

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The care at the hospital is horrible. It's uncoordinated, nobody communicates with one another and the list goes on and on. Documentation....the charts are a mess.

The "very high standard" to reassess and document pain every hour is a bunch of bull. The nurses there are so overworked and undertrained that they can barely do what they need to do.

WMC needs some serious help. I hope one day one of the big, good hospital systems comes and picks them up.

[Guest Photounit]

"I hope one day one of the big, good hospital systems comes and picks them up."

Seth,

I have to chime in on this one...... If you think that if some big hospital sysytem comes in and picks them up things will get better, I have to say I DOUBT IT....... These big hospital systems are all out to do one thing.... Make money for the shareholders....Patient care comes second....... I just lost my father from what amounted to repeated gross neglegence... My dad was in a ward where the patient/nurse ratio was 12 to 1. He needed more attention than what a nurse with 12 patients could offer but did not justify the 1 to 1 of what ICU offered. There was no intermediate ward that offered any lower paitient/nurse ratio, it was 12 to 1 or 1 to 1.... With a ratio of 12 to 1 he basically was neglected, his condition deteriorated until he needed to be placed in ICU and by then, it was too late.....These big hospitals are out to cut costs and maximize profits and I saw this first hand with my dad..... If anyone thinks anything else, you're only kidding yourself......The hospital/healthcare system in this country is in need of major repair and as long as profits are more important than patient care, things will never change....... The insurance industry is the other half of the problem....Sorry, I'll get off my soap box now........

[Guest Photounit]

I should have mentioned one thing....My dad WAS NOT in WMC....

[Goose 188]

So...can someone remind me WHY we fly/transport patients there?! Seems like its more for the term "regional trauma center" than the care they are provided with....

The only thing i have to say is that i would hold off on carpet bombing every hospital in the US health care system. Clearly, there exist a number of major national and regional issues that effect just about every facility/system. Money is a major issue, clearly. However, there are a number of facilities which have spent a great deal of money to improve their patient care. Two facilities in particular come to mind, Vassar Brothers MC and Greenwich Hospital. Both have spent figures well into the millions to improve patient care, outcomes, and minimize accidents. Just off the top of my head, i can think of Vassar's bar coding program as one step in the right direction.

[Guest alsfirefighter]

We transport and fly people there because they are the closest Level 1 Trauma Center we have. While I have to agree with some of the assessments mentioned of the admin on the floors and in some cases that attitudes of those involved on the floors...I have never seen or experienced any problems in the area of trauma patients. The floor isn't my problem...taking a patient where the staffing and equipment to give them the best possible chances of survival is.

[IzzyEng4 427]

Two facilities in particular come to mind, Vassar Brothers MC and Greenwich Hospital.

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Just an FYI, Greenwich is not a trauma facility under CT statues but if that is the closest hospital, a patient can go there for stabilization before sending out to a trauma facility. As for general medical, MIs, ect. they should be open to all categories.

Hope this helps out. I'm not familiar with WC hospitals but I know WMC is the big one out there. I know that up here in CT Yale-New Haven Hospital and Bridgeport Hospital are a co-op hospital.

If they area in need for help then they should look into a co-op with another (trauma) hospital.

A question for you all since I'm not familiar, is WMC's supported by the county or is it private?

[helicopper 1,050]

A question for you all since I'm not familiar, is WMC's supported by the county or is it private?

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That's a really good question!!! Depends on where you stand, I guess. Westchester County just bailed them out of major financial difficulty but they still profess to be a private hospital. The County tries to assert some oversight control but I don't know that they have the authority to stop the hospital.

Clear as mud, eh?

[Remember585 815]

The WMC made me SHARE A BED with someone having an asthma attack on a nebulizer while I was on oxygen myself!

GREAT HOSPITAL!

They also put me into hyperbarics not for my own condition but to promote their "new" hyperbaric unit. Just look in the Journal News (or whatever it was called) around 12/29/99. Me and my buddy were barely into the damn things and their photographer was setting up a tripod!

[Goose 188]

Just an FYI, Greenwich is not a trauma facility under CT statues but if that is the closest hospital, a patient can go there for stabilization before sending out to a trauma facility.  As for general medical, MIs, ect. they should be open to all categories.

Hope this helps out.  I'm not familiar with WC hospitals but I know WMC is the big one out there.  I know that up here in CT Yale-New Haven Hospital and Bridgeport Hospital are a co-op hospital.

If they area in need for help then they should look into a co-op with another (trauma) hospital.

A question for you all since I'm not familiar, is WMC's supported by the county or is it private?

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I know its not a trauma center, i was speaking about facilities/medical groups more generally with my second comment. Thanks for the info none the less.

ALS, i was being sarcastic lol. I haven't brought many patients there, but when i have i haven't encountered any problems in the ER. I guess its a different ball game up in the units.

I THINK its a private with some county funding...i think the county recently bailed them out of some fiscal problems

[helicopper 1,050]

We transport and fly people there because they are the closest Level 1 Trauma Center we have. While I have to agree with some of the assessments mentioned of the admin on the floors and in some cases that attitudes of those involved on the floors...I have never seen or experienced any problems in the area of trauma patients. The floor isn't my problem...taking a patient where the staffing and equipment to give them the best possible chances of survival is.

So they survive the trauma that brought them there, they're successfully treated in the ER/OR, then they die on the med surg unit???? That's not very encouraging!!! Maybe it is time for an alternative.

The following is what I find interesting. Why the big secret? Isn't this stuff all a matter of public record? None of this makes them look very good!

Westchester Medical Center refuses to release survey

By MELISSA KLEIN

THE JOURNAL NEWS

(Original Publication: July 12, 2007)

VALHALLA - Westchester Medical Center is refusing to release a copy of its latest accreditation survey and the follow-up reports that resulted in a rating downgrade.

The medical center, which is a public benefit corporation and subject to the state's Freedom of Information law, declined a request from the Journal News to provide the reports.

The hospital's accreditation from the Joint Commission, a national standards organization, is considered provisional because it failed to meet its own standards for assessing and documenting pain. The provisional rating means it is not in full compliance with all applicable standards.

The Journal News submitted a request last month for copies of the Joint Commission's August 2006 survey results, which had 13 requirements for improvements. The request also sought any follow-up reports or results.

In denying the request, the medical center in a letter dated Monday said it was "prohibited" from disclosing "quality improvement information" under state public health and education laws.

It also said its contract with the Joint Commission provided confidentiality protection to the reports.

Robert Freeman, executive director of the state Committee on Open Government, said there seemed no basis for the medical center to withhold the documents.

"Since this document is in the possession of a governmental entity, the Freedom of Information Law would apply and in my opinion require disclosure," Freeman said.

Even a trade association to which the hospital belongs said there was no prohibition against releasing the report.

Lorraine Ryan, special counsel, regulatory and professional affairs, for the Greater New York Hospital Association, said the hospital did have protections under the health and education laws, but there was nothing to prevent it from making public the report.

"They could if they want to, but they don't have to because they enjoy these protections," Ryan said.

She said most hospitals nationwide do not release survey reports.

Ryan said the New York law was designed to protect a hospital's quality improvement efforts, because if those activities were made public, certain weaknesses in care might be revealed.

"They're protected in order to encourage those activities to make care safer and patient care better," Ryan said.

Elizabeth Zhani, a spokeswoman for the Joint Commission, said it was up to a hospital whether it wanted to release a survey.

"If they'd like to release it, they can," she said.

The Joint Commission accredits most of the nation's hospital and results of its surveys are on its Web site. The full survey reports are not disclosed by the organization.

The medical center released a statement yesterday saying "as a public benefit corporation Westchester Medical Center is one of the most transparent hospitals in the state of New York."

"Regardless of the content, either positive or negative, it is an industry practice for both public and private hospitals not to release quality assurance information," the statement read.

In 2001, the medical center did provide a copy of Joint Commission survey results to The Journal News.

That year, the hospital received a conditional accreditation, which is one step below provisional, after a Joint Commission survey team caught a medical resident and several nurses altering a patient's chart. Missing information had been added to the chart and backdated. The rating was upgraded later in the year.

After the most recent survey, the medical center was required to fix any deficiencies and demonstrate sustained compliance to what is called a "measure of success."

The medical center has said it had three areas in which it had to conduct self-assessments including the documentation of reassessing pain.

Kara Bennorth, a spokeswoman for the medical center, has said the hospital set its own high standard that 90 percent of the time it would do hourly reassessments of a patient's pain and document that. It had fallen short on the documentation, she said.

The medical center has until the end of August to show the Joint Commission that it is in compliance.

[ONEEYEDMIC 68]

OK I just read some of this thread. I had a pretty serious accident in 1993 and went to WCMC at the time. I had just taken my EMT class and was riding with a LOCAL VAC at the time and I happened become friends with an ER DOC who I think is and AWESOME GUY. Anyway, I knew the seriousness of my injury and immediatley told the ER triage nurse who could see that it was serious. Dr. Larsen the attending that day and who I believe now runs the ER DEPT came out and recoginzed me and stayed with me the WHOLE time. He took me XRAY while and talked to me while I was being evaluated by other DR's in the ER. I remember the ER being crowded that day but he didn't forget about me. We became pretty good friends after that and the next year I became a MEDIC and I used to see him all the time. Never gave me hard time about using VALIUM, MORPHINE, ETC.... I would actually call him and tell him that I already gave it and he had no problem with that. I was pretty aggressive and he knew that I knew what I was doing. After I became a LEO, I ran into him in the ER and he brought up the day of my accident that was almost 10yrs prior. All DR's should have the kind of RAPPORT with their patients and their COLLEGUES.

As a MEDIC I never liked going to that ER. Most of the NURSES were B*tches all the time and the ER DOC's changed. Plus the fact that you would have to give report to a STUDENT DOC sometimes then tell your story all over again to the RESIDENT or ER ATTENDING annoyed the crap out of me. Don't get me wrong, not all of the staff there are MEAN AND GRUMPY. Just some.

I have stated though, GOD FORBID something happens to me while I am work, I want to be taken to JACOBI. I have been there only a few as a MEDIC, but I know that they know their stuff. I still have faith in WMC since I am about 20 seconds from there, I just wish they would get their sh*t together.

[mikerabbit 2]

Dr. Larsen and Dr. Hadock both left WMC and are the White Plains ER Directors. I have seen a lot more of the WMC docs go to WPER.

[ONEEYEDMIC 68]

Dr. Larsen and Dr. Hadock both left WMC and are the White Plains ER Directors. I have seen a lot more of the WMC docs go to WPER.

I guess I haven't been there in awhile. LOL

[WAS967 97]

The reason a lot of the ER doctors we had grown familiar with left is because there was a change in the contract and a new physician's group based out of NJ (the name escapes me) is now providing docs for WMC's ER. They are the same group that provides the MDs for HVHC, so it's not uncommon to see some of the docs from HVHC working at WMC.

[Guest]

I am not going to bash any hospital but, having taken hundreds of patients to both WMC & Jacobi, I have 2 cents worth of advice for you...if you like your patients take them to Jacobi. Another piece of advice for the LEO's on this board...write "Take me to Jacobi" on your vests!!!

[ONEEYEDMIC 68]

I am not going to bash any hospital but, having taken hundreds of patients to both WMC & Jacobi, I have 2 cents worth of advice for you...if you like your patients take them to Jacobi. Another piece of advice for the LEO's on this board...write "Take me to Jacobi" on your vests!!!

I have thought about it. In all realistics, WMC is so much closer if something did happen that I know that I would wind up there. Just would hope they would do the best job on me.

[Guest]

I'm sure that we all agree that Jacobi is the place to go. But that still doesn't respond to the big question. That is, what does the future hold for the only "Regional Trauma Centre" in our area. Yes, big hospitals have now turned into big businesses. Money and the shareholders are the priority. Propoganda and the apperance of legitimacey are more paramount than being legitimate in actuallity. So what does this big conglomeration have to do to stay out of troulbe? Makes one wish that the WMC were back to being county run. At least then there would be a few more checks and balances enforced. How do big hospitals that are city/county/state owned run. Every penny is scrutinized, yet what needs to be done is done, and what care needs to be given is rendered. It is becoming rapidly clear that surrounding hospitals need to ugrade their status to be able to provide surgical and broad care in a short time, meaning getting as close to a trauma accreditation as possible. It's not like we're not sending trauma patients to other hospitals when need be. Our over relliance one one hospital to provide our trauma and specialty services is dragging us down. It's time that other smaller hospitals (escpecially up here in the sticks) get a move on and man up to their responsibilities or APPROPRIATELY caring to patients with a multitude of ailments.

My 2 cents.....I have no faith whatsoever in the Medical Centre as it stands today. The fact they are slashing wages, employees and benefits for future and current employees doesn't help the matter much. The employees grudge against the hospital is only taken out on our patients. Trauma, take me to Jacobi. Medical, take me to Columbia Pres.