Based on a March 6 on-site evaluation initiated by complaints stemming from the Jesica Santillan case, the Joint Commission on Accreditation of Health Care Organizations has downgraded Duke Hospital's accreditation status from "Accreditation with Full Standards Compliance" to "Accreditation with Requirements for Improvement."
JCAHO, the national accrediting body for hospitals and other health care institutions, cited six performance areas--among 45 total--in which the Hospital received a substandard grade: aggregation and analysis, planning, role in improving performance, assessing competence, information management planning and governance. The review noted inadequate confirmation procedures that may have contributed to the Feb. 7 mistake involving Jesica, in which a heart and lungs of incorrect blood type were transplanted into the 17-year-old girl. JCAHO also pointed to inadequate documentation of the transplant surgeons, and questioned the qualifications and training of the procuring surgeon.
The Hospital's Director of Accreditation and Regulatory Affairs Gail Shulby responded to reviews reported by both JCAHO and the state Division of Facility Services in a March 21 statement, noting that the Hospital conducted its own review following the tragedy and noted many similar areas needing improvement. In addition, the Hospital has already enacted many needed changes, including instituting repeated verifications of blood match for transplant, the statement said.
"We continue to review the circumstances surrounding Jesica's care and welcome the input from these agencies to further enhance our programs," Shulby wrote in the statement. She noted DFS will return March 24 for a full validation survey, and JCAHO will return within three months for a focused survey.
The Hospital was last downgraded in status in December 2000. At any one time, approximately 89 percent of hospitals hold the "Accreditation with Requirements for Improvement" status.
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