Mercy Healths Brain Tumor Center Earns Recertification from The Joint Commission

Mercy Health’s Brain Tumor Center at The Jewish Hospital has been recertified by The Joint Commission, earning the Gold Seal of Approval® for brain tumor care. It is only the fourth center of its kind in the nation to earn this certification by demonstrating continuous compliance with The Joint Commission’s performance standards. The Gold Seal is a symbol of quality that reflects a health care organization’s commitment to providing safe and quality patient care.

The certification recognizes health care organizations that provide clinical programs across the continuum of care for brain tumors. The certification evaluates how organizations use clinical outcomes and performance measures to identify opportunities to improve care, as well as to educate and prepare patients and their caregivers for discharge.

“The Brain Tumor Center at The Jewish Hospital underwent a rigorous virtual review that was detailed, intensive, collaborative, and consultative. The surveyor observed many best practices and was impressed with the dedication that the team demonstrated in providing excellent care to their patients,” said The Jewish Hospital President Pat Davis-Hagens. “I congratulate every member of the team for the dedication they have to delivering exceptional patient care.”

The Joint Commission develops its standards in consultation with health care experts and providers, measurement experts and patients. The reviewers also conducted onsite observations and interviews.

The Brain Tumor Center’s 22 physicians specialize in neurosurgery, otolaryngology (ear, nose and throat), radiation oncology, medical oncology, neurology, neuropathology, neuroradiology and rehabilitation medicine. The center also includes the only skull base brain tumor program featuring fellowship-trained neurosurgeons and ENT surgeons, the region’s only Gamma Knife® ICON™ radiosurgery program, a multidisciplinary Brain Tumor Board and a nationally recognized bone marrow transplant program.

“Brain Tumor Certification recognizes health care organizations committed to fostering continuous quality improvement in patient safety and quality of care,” says Mark Pelletier, RN, MS, chief operating officer, Accreditation and Certification Operations, and chief nursing executive, The Joint Commission. “We commend Mercy Health’s Brain Tumor Center for using certification to reduce variation in its clinical processes and to strengthen its program structure and management framework for brain tumor patients.”

Some of the preparation for the site review included a review of the interdisciplinary team; the program’s mission and scope of services, organization chart and job descriptions; emergency and medical equipment plans; order sets; clinical pathways and protocols used to implement the clinical practice guidelines. The Brain Tumor Center Team also reviewed education material for patients, families and the community; policies and procedures; clinical and non-clinical performance measurement data together with continuous quality improvement reports; action plans to demonstrate how the data is used to improve program care and services; physician credentials; meeting minutes and conference calendars and agendas. The reviewer verified the effectiveness and performance of the program by speaking with patients, staff, providers and through observational and chart audits.