Maui hospital receives zero “Condition Level Findings” from accrediting body

Maui Memorial Medical Center received zero “Condition Level Findings” during an unannounced visit by surveyors with The Joint Commission in July. This marked the hospital’s highest scores to date, according to a Maui Health press release.

Surveyors arrived on July 25, for a multiple day, on-site survey that assessed the hospital’s compliance with 278 Standards, 1,499 Elements of Performance, and 11 National Patient Safety Goals.

TJC is the nation’s oldest and largest standards-setting and accrediting body in health care, and conducts tri-annual surveys. TJC sends a team of surveyors, unannounced, once every one to three years, depending on previous survey results and any corrective action needed.

With zero “Condition Level Findings,” the Maui facility performed above national standards, according to the release. An estimated 52% of hospitals throughout the country receive at least one finding. According to TJC, in 2016, 32% of hospitals had at least one condition level finding and in 2017 that number increased to 49%.

“The pandemic has put continued strain and pressures on hospital staff and resources over the past three years. This and the fact that The Joint Commission has expanded standards to conform to CMS expectations and have also tightened down their survey process is evidenced by the increased percentage of condition level findings during hospital surveys across the nation,” said Marie Falcis-Pickell, Maui Health Director of Quality, Patient Safety and Performance Improvement. “Even in the face of these challenges, MMMC continues to improve in the quality and safety of care provided and we are so proud of our team.”

MMMC also received fewer “Elements of Performance” findings than in the previous surveys conducted in 2017 and 2019, with zero high-risk findings in the top four areas of TJC focus including suicide prevention, high level disinfection and sterilization, and sterile medication compounding and hemodialysis. Additionally, there were zero “Leadership Standards” cited.

In an exit briefing at the end of their visit, Joint Commission surveyors lauded staff’s “confidence and engagement and dedication and knowledge of the patients’ care needs” and praised the “collaboration between physicians and nurses” as well as MMMC’s “excellent infection control and pharmacy programs,” according to the Maui Health news release.

“To pass a survey as rigorous as one from The Joint Commission, especially in the midst of a pandemic and unannounced months earlier than anticipated, takes sustained, collaborative work on a daily basis,” said Mike Rembis, Maui Health CEO. “Our team’s commitment to our mission to provide exceptional health care for the people we serve with compassion, dignity and respect was undeniably clear and I am incredibly proud.”

TJC, an independent not-for-profit organization, accredits and certifies more than 22,000 health care organizations throughout the United States.

The survey comes following recent reports by the Honolulu Star-Advertiser of Emergency Room doctors voicing concerns, and Hawaii News Now in which a trauma surgeon spoke out, starting an online petition, and demanding resources and change amid a loss of physicians.

A spokesperson with Maui health responded to Maui Now’s request for information saying a physician, nursing and overall healthcare exodus of workers is a “widely documented, national (albeit global) issue.”

“It is not indicative of Maui, but we are certainly experiencing the affects, as our hospitals across our state. This was a trend that began even before the pandemic, but the challenges of the last 2+ years has exacerbated the issue,” said Maui Health spokesperson Tracy Dallarda.