Stanford Health Care lauded for quality, transparency during Joint Commission survey

When surveyors from The Joint Commission conducted their triennial accreditation survey earlier this summer, Stanford Health Care passed with flying colors.

- By Amy Jeter Hansen

David Entwistle

Notification appeared via secure website around 7:15 a.m. on June 17. Glued to their smartphones, as they had been every Monday morning for 18 months, Stanford Health Care’s Accreditation, Regulatory and Licensure group sprang into action.

At 7:20 a.m., senior quality consultant Catherine Sun sent an email alerting more than 880 employees:

“The Joint Commission has arrived!”

It was the beginning of a five-day journey that would span the entire Stanford Health Care enterprise, including the main hospital and dozens of ambulatory clinics. Nine surveyors from one of the nation’s oldest and most respected health care accreditors had dropped in to conduct their customary, painstaking review of compliance with patient safety and quality standards — an on-site evaluation that happens every three years for accreditation renewal.

Stanford Health Care’s showing was particularly impressive this time around, said president and CEO David Entwistle. “We had one of our top surveys yet,” he said. “Not only did we demonstrate meticulous adherence to safety and quality standards, but the surveyors also lauded our culture of transparency — how helpful we were on an ongoing basis, how quickly we completed tasks, how responsive we were to what they needed.”

Accreditation from The Joint Commission certifies that a health care organization continues to meet or exceed meticulous procedural standards that align with government requirements, making the organization eligible for reimbursement through Medicare and Medicaid. It also signals a hospital’s commitment to developing and adhering to rigorous policies governing everything from provision of care to food preparation to data management.

“Having surveyors in here, helping us to see ourselves more clearly, is a good thing, and we take that feedback from The Joint Commission very seriously,” said Quinn McKenna, Stanford Health Care’s chief operating officer. “We want to be on the top decile as a leading major academic medical center in the country with regards to quality, safety and patient outcomes. And getting a strong, good survey is part of that journey.”

Setting health care standards

Based in Illinois, The Joint Commission is an independent, nonprofit organization that for nearly seven decades has set health care standards based on expert consensus and scientific literature, and evaluated organizations’ compliance with those standards.

The survey itself is a grueling process; its scope is comprehensive. Surveyors may visit any area, ask questions of any staff member at any time and request documents and other information related to the survey. 

To manage logistics, Stanford Health Care leaders set up a survey operations center for the week. Each of the nine surveyors was accompanied by an escort and scribes, and liaisons from Stanford Health Care were assigned to assist.

“Approximately 100 patient medical records were reviewed by the surveyors, along with numerous policies and procedures, and employee files. In addition, the surveyors spoke with 464 staff members,” Sun said.

Stanford Health Care administrators, physicians and staff participated in presentations and discussions on such topics as leadership, data management, infection prevention and medication management. Surveyors also could take a deep dive into specific areas using a “tracer” methodology: They could focus on one topic, such as medication administration, across the organization, or they could follow a randomly selected patient’s journey from admission to discharge.

“It’s a very fluid process,” said Maureen Doherty, RN, manager of accreditation and regulatory affairs. “Some of the surveyors may have an initial plan or focus in mind, but then decide to change plans based on what they have seen. We have to be prepared and nimble in accommodating their requests across the organization, and that requires excellent communication across a well-coordinated team.” 

Praise from surveyors

Shortly after the survey, Stanford Health Care leaders learned that the organization’s accreditation had been renewed. Mark Pelletier, RN, The Joint Commission’s chief nursing executive and chief operating officer for accreditation and certification operations, provided this written comment: “We commend Stanford Health Care for its continuous quality improvement efforts in patient safety and quality of care.”

As is customary, comments from the surveyors were offered verbally, and Stanford Health Care officials reported that the surveyors were pleased with what they saw — even noting areas in which Stanford is a model for other organizations. In particular, surveyors praised kitchen services, the use of data for improvement and the scope and scale of ambulatory care services.

“When they came to our clinics and our units, there were teams of people waiting to show them around and talk with them,” said Lisa Schilling, RN, vice president of quality, safety and clinical effectiveness. “The attitude, the leadership, the seriousness and the collegiality that we offered was really notable to them.”

Norman Rizk, MD, chief medical officer, characterized the survey as “a very good visit” but cautioned against becoming complacent. Surveyors will return to evaluate the new Stanford Hospital, potentially as soon as the day after it opens.

“The goal generally is to become the best at getting better,” Rizk said. “It’s our responsibility to the public — and to each other.”

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit