Stroke Program Manager Mariah Mossman, RN, and Infection Prevention Manager Kelly Catiel, RN, perform an impromptu farewell hula for the surveyors outside in Maui Memorial Medical Center’s courtyard, with music provided by ‘Ohana Groove. The lunchtime “Aloha Friday Music” concluded Maui Health’s month-long five-year anniversary celebrations that included weekly activities, including Aloha Friday music, farmer’s market, massages, snacks and more.

WAILUKU — Maui Memorial Medical Center (MMMC) is proud to share the successful completion of its tri-annual Joint Commission survey last month. Official survey results were received last week and confirm the week-long survey was MMMC’s most successful survey in hospital history.

The Joint Commission (TJC) is the nation’s oldest and largest standards-setting and accrediting body in health care. On Monday, July 25, three TJC surveyors arrived unannounced at MMMC and spent the week assessing the hospital’s compliance for 278 Standards, 1,499 Elements of Performance, and 11 National Patient Safety Goals.

MMMC received zero “Condition Level Findings,” performing above national standards with 52 percent of hospitals throughout the country receiving at least one finding. According to TJC, in 2016, 32 percent of hospitals had at least one condition level finding, and in 2017, that number increased to 49 percent.

“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.”

The surveyors also commended MMMC’s “work to build a value-based culture,” among many other complimentary comments, including that “leadership engagement is visible at all levels of the organization,” that “it is clear that all staff are committed to doing what is best for their patients” and “leaders care for their patients as well as their employees.”

“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 accredits and certifies more than 22,000 health care organizations throughout the United States.

As an independent, not-for-profit organization, TJC seeks to continuously improve health care for the public by evaluating health care organizations to ensure rigorous quality assurance and patient safety standards are being met.