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Straight Talk
A weekly update from management on the issues that matter most.

Jun 28, 2018
Highlighting a culture of high expectations, NCH is the only healthcare system in Southwest Florida with all of its facilities—out-patient and in-patient—reviewed and accredited by The Joint Commission (TJC).

Last week we had eight to ten, depending on the day, competent and experienced Joint Commission surveyors educating, consulting, validating, uncovering, connecting, simplifying, and sharing best practices with us.  Our entire out-patient system with 73 locations from Bonita to Marco Island to east of I-75 on Immokalee Road as well as our Baker Hospital (385 beds) and North Naples Hospital (325 beds) were examined for quality and safety. 


For over 60 years, TJC has been a champion of patient safety by helping healthcare organizations to improve the quality and safety of the care provided.  TJC’s many patient safety-focused initiatives encourage and support organizations like ours as we make patient safety and high quality continuous priorities.


Raising the bar, sustaining a culture of high expectations, and learning best practices from experienced healthcare professionals—physicians, nurses, and engineers—who collectively have examined hundreds of other healthcare systems help our 4,300 colleagues, 800+ physicians, and 200+ non-physician providers continuously improve.  Having an independent set of eyes look over brand-new and long-existing services and locations uncovers areas for improvement and adds value. 


Director of Accreditation & Regulatory Compliance Dora Krauss, Director of Infection Control Georgine Kruedelbach, System Safety Officer Bill Smith, and Director of Facilities Lee Wehr organized multiple teams to accompany our surveyors.  As many of our colleagues as practical rounded with our surveyors while they traced patients throughout our system.  In addition to validating compliance and collaborating on quality, these “rounds” focused on education and sharing best practices.  TJC has a comprehensive library of 800+ best practices.


Some of the many best practice recommendations touched on end-of-life issues, disposal of narcotics in the midst of the national opioid crisis, enhanced screening for domestic violence, simplification of the credentialing process and sterilization/disinfection of surgical packs.  All of these appropriate suggestions were accompanied by contemporaneous learning moments as our surveyors helped the involved staff to understand the “how” and “why” these changes improve quality and safety.


Our examiners agreed that we provide excellent quality, but have opportunities for better documentation in areas of rapid recent growth that are ripe to standardize best practices.  Overall, we have learned and will quickly comply with all the appropriate suggestions.  We expect another visit to validate our learnings in the near future and will continue on our never ending journey of improvement.


Learning together, sharing best practices, and receiving review by outside, independent, competent folks accelerate our journey to help everyone live a longer, happier, and healthier life.


P.S.  DO YOU HAVE A COLLEAGUE OR FRIEND WHO WOULD BE INTERESTED IN UPDATES?  Please enter their email address at, and we will add them to our complimentary mailing list.  


Allen Weiss, M.D.

President and CEO

You may contact Dr. Allen Weiss and The NCH Healthcare System by clicking here.