Achieving accreditation by The Joint Commission reflects an organization’s dedication and commitment to meeting standards that facilitate a higher level of performance and patient care. By meeting these standards, we received The Joint Commission Gold Seal of Approval® – an internationally recognized symbol of quality. The Joint Commission accredits more than 20,500 organizations worldwide and focuses on continually improving health care by setting the highest standards for health care quality throughout the world. In setting the standards, The Joint Commission consults doctors, nurses, and quality and safety experts to review the current standards and make recommendations for improvements.
The Gold Standard: The Joint Commission
Accreditation means that our staff has made an extra effort to review and improve the key areas that can affect the quality and safety of your care. Accreditation by The Joint Commission is considered the gold standard in health care. Specially trained health care professionals who are experts in their fields visited Hospice Savannah to conduct a review that monitors how well our staff:
- provide a safe environment for your care
- educate you about the risks and options for your diagnosis and treatment
- protect your rights as a patient, including your privacy rights
- evaluate your condition, before, during and after diagnosis and treatment
- protect you against infection
- plan for emergency situations.
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Other Quality Measures:
CMS CAHPS
The CAHPS® Hospice Survey gathers information on the experiences of hospice patients and their informal caregivers’ perspectives of their loved ones’ care with hospice services. Consumer Assessment of Healthcare Providers and Systems Hospice Survey (CAHPS). The Hospice CAHPS® Survey samples the primary caregivers of deceased hospice patients who meet survey criteria. Survey administration will occur several months after the death. The survey includes the following key topics: starting hospice care; help for the patients’ symptoms, communication with the hospice team, caregivers’ own experiences with hospice care services; an overall rating of hospice care, and a question about willingness to recommend the hospice.
The Deyta/HealthcareFirst company is Hospice Savannah’s chosen vendor to administer the CMS CAHPS Survey. In addition to the CAHPS required questionnaire, Deyta also collects data on veterans services and other services provided by Hospice Savannah, which Deyta provides results and comparisons at a state and national level. In the most recent survey, 4/01/2019 – 9/30/2021 data, the national average for “Would you recommend this hospice” (Definitely Yes) was 84% and the Hospice Savannah average was 90%.
CMS maintains a Hospice Quality website where data showing comparisons between various hospices is available for the public’s review.
| Hospice Savannah Inc. | National Average | |
| Willingness to recommend this hospice | 90% | 84% |
| Rating of this hospice (scale of 1 to 10, higher the better) | 82% | 81% |
| Getting timely help | 83% | 78% |
| Treating patients with respect | 91% | 90% |
| Emotional & Spiritual support | 91% | 90% |
| Help with pain & symptoms | 77% | 75% |
| Training family to care for patient | 78% | 76% |
In the FY2022 Hospice Final Rule, CMS finalized public reporting of CAHPS Hospice Survey Star Ratings. Beginning with the August 2022 refresh of Care Compare, a Family Caregiver Survey Rating Summary Star Rating will be publicly reported for all hospices with 75 or more completed surveys over the reporting period. Star Ratings are updated every other quarter. Hospice Savannah’s first Star Rating is four stars.
| Hospice Savannah’s Rating | |
| Family Caregiver Survey Rating | 4 |
| Star rating for each CAHPS Hospice Survey quality measure | |
| Communication with family | 3 |
| Getting timely help | 4 |
| Treating patient with respect | 4 |
| Emotional & spiritual support | 4 |
| Help for pain & symptoms | 4 |
| Training family to care for patient | 4 |
| Rating of this hospice | 3 |
| Willing to recommend this hospice | 4 |
Hospice Item Set
Additionally, the Hospice Item Set (HIS) is a patient-level data collection tool developed by the Center for Medicare and Medicaid (CMS). We are required to submit a HIS Admission record and a HIS Discharge record for each patient which are used to compare quality measures between various hospices. Find out how we compare to other local and national hospices here.
Hospice Care Index (HCI)
The HCI is a new 2022 measure that captures care processes occurring throughout the hospice stay, between admission and discharge. The HCI is a single measure comprising ten indicators calculated from Medicare claims data. The index design of the HCI simultaneously monitors all ten indicators. Collectively these indicators represent different aspects of hospice service and thereby characterize hospices comprehensively, rather than on just a single care dimension. Each indicator equally affects the single HCI score, reflecting the equal importance of each aspect of care delivered from admission to discharge. CMS data collected between 4/01/2019 – 9/30/2021.
Hospice Savannah: 10
State: 8.8
National: 8.8
A Culture of Patient Safety
We want all our staff, volunteers, patients and their families to know that if they feel Hospice Savannah has not adequately prevented or corrected problems that can have, or have had, a serious adverse impact on patients, they are encouraged to report concerns to either Julie McGowan, Compliance Officer, to Dr. Kathleen Benton, President & CEO, or directly to The Joint Commission.