UNC Hospitals expects to regain accreditation even though agency cited 44 issues

The Joint Commission on Accreditation of Healthcare Organizations made its report on UNC Hospitals public Wednesday, Aug. 28, citing a laundry list of 44 performance issues that cost UNC its clean status of accreditation. 

The Joint Commission inspected UNC Hospitals in Chapel Hill’s facilities in mid-July and placed it on probation after a preliminary denial of its accreditation. The Joint Commission is an independent, nonprofit accreditation organization that wields an almost quasi-governmental authority and certifies 80% of all new hospitals. 

The report demands UNC Hospitals “reduce the risk for suicide,” tighten the safety of its medication management, better assess patients, better prevent hospital-acquired infections, and address concerns with its facility.

“In some cases, we may have missed a component or part of a standard, or failed to provide documentation of a component,” UNC Health Care said in a statement. “However, there was no finding of immediate threats to patient health and safety.”

Many of the performance issues have to do with building features — from risks with its utility systems to the reliability of its emergency power system. A handful deal with fire safety. 

But some relate directly to patient health. The JC demanded better patient assessment — especially of patients’ risk of falling, possible abuse or neglect, and the needs of patients with substance abuse disorders. The JC also required better care before and after “high-risk” procedures. 

The report twice instructs UNC Hospitals to better prevent hospital-acquired patient infections, requiring UNC to build a “infection prevention and control plan” to reduce “the risk of infections associated with medical equipment, devices, and supplies.” 

UNC administrators don’t expect its accreditation problems to linger. The Joint Commission accepted its Plans of Correction on Aug. 22, and UNC leadership believes commission surveyors will return to inspect the facility as soon as this week. 

“UNC Hospitals’ leadership is confident that we have addressed all of the Commission’s findings, and that the preliminary denial of accreditation status will be lifted,” UNC Health Care said in a statement. “We are committed to continuous quality improvement, and working with the Joint Commission is an important part of that ongoing effort.”