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Quality Corner: Congratulations to Community Memorial Hospital in Burke on a Successful Survey

The Community Memorial Hospital (CMH) in Burke, South Dakota had surveyors at their facility the week of April 24, 2023. While surveyors are not unusual, this week proved to be a challenging week for the CMH, which happened to coincide with the surveyors visit.  In the end, CMH had a successful survey regardless of their struggles. Success happened due to the CMH team being prepared, remaining calm and being flexible. Here is how they did it.

The surveyors arrived at 1pm on Monday, April 24 and stayed until 3:30pm on Wednesday, April 26. The hospital was very busy these days including both floor and ER patients, also adding a need for a helicopter from the Sanford flight team for one of their ER patients.    Through it all, the surveyors kept things moving, were educational and willing to work with the hospital’s schedules – all while watching the CMH staff work, during some unusual circumstances. The staff from the hospital said the surveyors were very nice and treated the staff with respect.

Community Memorial Hospital

Being prepared in advance proved to be key for the CMH team.  The hospital’s CEO, Mistie Drey, had put a binder together for items that may be needed during a survey.  Tammi Hotz, DON stated, “thank goodness we had that binder as we were able to pull information from it to help us make the survey process smoother”.

The surveyors did ask for a report that the facility was not aware of but the CMH team were able to locate quickly for the surveyors.  This report was specific with patient names and their diagnoses on it.  The surveyors recommended they run this report monthly.  The facility now has this in their monthly practices.

Two of the surveyors followed in the Emergency Room, watched an outpatient dressing change, a telemedicine visit, and watched nurses pass meds. The DON and the discharge planner from the hospital navigated charts for the surveyors as they asked. The surveyors went through:

  • Inpatient
  • Swing Bed
  • Emergency Room
  • Death Charts
  • Outpatient charts

Some specific things the surveyors asked for included:  consents, transfer forms, and flowsheets.

The surveyors also looked at:

  • Orders
  • Notes
  • Discharge Planning
  • Dietician
  • PT/OT Notes.

Surveyors followed PT/OT as they did therapy visits with patients. Other things they asked for were infection control documentation, quality assurance forms, and blood banking forms. Surveyors also followed maintenance, housekeeping, and pharmacy.  Additional documents requested by the surveyors included, employee files and employee health documentation. The surveyors commented how impressed they were with the Emergency Room staff and how calm they were during a serious emergency that required the flight team from Sanford to come and take the patient via helicopter to Sioux Falls.

Be prepared and calm paid off for CMH, as they are celebrating this week! The surveyors provided insight on how to fix some forms and a couple of changes in the maintenance department, however, they did not give any deficiencies and gave CMH a very successful survey. Congratulations to all the staff at the Burke Hospital! 

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