Hospital’s overall correction plan is to reassess policies and procedures

The only public hospital in the CNMI has just four days left to submit its plan on how it will rectify the remaining concerns of the Centers of Medicare and Medicaid Services. Otherwise, its condition of participation in Medicare will be terminated.

If the Commonwealth Healthcare Corp. fails to turn in its plan of correction by Dec. 22–this coming Monday–CMS will proceed with terminating the hospital’s Medicare provider agreement on April 3, 2015. That would mean the loss of millions of dollars the corporation relies on to run the Commonwealth Health Center.

The plan of correction CHC needs to come up with must address six deficiencies: in its governing body, patient rights, medical staff, medical record services, physical environment, infection control, and discharge planning.

The corporation’s chief executive officer, Esther Muna, said that one of the big focuses of the plan of correction is reassessing its policies and procedures so that everyone is in line with their work at the hospital.

“We need to go back and reinforce the training on our policies and, as what I’ve discussed with the hospital administrator [Jess Tudela] is that we’re taking a different approach this time,” Muna said.

That new approach is basically bringing more teamwork into play and giving more ownership to the staff and management in implementing the policies.

According to Muna, the hospital staff has been having small meetings on ways to address the concerns raised by CMS.

“So we’re having daily meetings and we’re taking the approach in a way that makes everybody involved in the input of what we decide or how we’re going to address the issues,” Muna said.

“What we notice is that we just really need to remind ourselves and do training and we have to try to make sure and remember our policies and procedures,” she added.

Muna also said that part of the plan of correction is to address patient rights, to encourage patients to speak out if they are not getting the care they need or if they have any concerns.

“We also want to encourage the patients to speak out if they see something that they are uncomfortable with. They can bring it up to the nurses if they want to because it’s their right,” Muna said.

“We want patients to understand that this is their hospital and let them know that. We have a grievance procedure if they have an issue with the care that they receive,” she added.

Muna said they have posted so many posters about those patient rights or responsibilities.

“So we have been having these meetings and this is not that we came up with this plan of correction for the sake of needing to have one, but we’re coming up with this because it has to be doable, practical, and have it done faster,” she said.