Author Archives: Trena Williamson

Joint Commission Preparation: Tip of the Week

July 2018 – Patient Visitation Update – Patient Support Person

What is a Patient Support Person?

A Patient Support Person is:

  • An adult family member, friend or other individual, designated by the patient, orally or in writing, that supports the patient during the hospital stay.
  • This person can change during the hospital stay if the patient’s wishes.
  • This person may or may not be the decision maker.

How does this relate to patients at UM Shore Regional Health?

  • UM Shore Regional Health believes that visitation is integral to the patient’s experience. The family and the Patient Support Person are valued partners in patient care and are a respected part of the care team.
  • Families and the Patient Support Persons are asked to work together with staff so that their presence does not limit staff access to the patient at any time.
  • The Patient Support Person may visit with the patient, and may also exercise a patient’s visitation rights on behalf of the patient with respect to other visitors, when the patient is unable to do so.
  • The CMS standard recognizes that “Although visitation policies are generally considered to relate to visitors of inpatients, “visitors” also play a role for outpatients who wish to have a support person present during their outpatient visit”. The UM Shore Regional Health Visitation policy is a system policy and applies to all care settings: Inpatient, Emergency and Outpatient.

Joint Commission Preparation: Tip of the Week


How do you, in your job support UM SRH’s mission (Creating Healthier Communities Together)?

Potential Answer/s:

  • I educate my patients regarding their medications and/or diet and/or home exercise program.
  • I refer my patients and their support person to community support groups such as a breast feeding or smoking cessation support group.

How do you, in your job ensure patient safety and support the National Patient Safety Goals?

Potential Answer/s:

  • I always use two patient identifiers when administering ordered medications, treatments or tests.
  • I always wash my hands (soap and water or hand sanitizer) before and after providing care.

What is your department’s/unit’s role in performance improvement (PI), or PI may be referred to as QAPI(Quality Assurance and Performance Improvement), or quality improvement?

Potential Answer/s:

To work on PI initiatives as set by our leaders.


  • We educate our patients and set up post hospitalization care to assist in reducing re-admissions.
  • We report all events, even ones that did not impact the patient. (Good Catch/Near Miss)
  • We implemented care transition rounds.
  • We implemented Quiet hours for our patients.
  • We implemented White Boards to improve communication with our patients.

How do you support and ensure our Patients’ Rights?

Potential Answer/s:

  • I ensure my patient’s support person (as identified by the patient) is involved in my patient’s discharge plan.
  • I explain care being providing prior to providing care and allow my patient to ask and
    have answered questions regarding their care.

How were you oriented and deemed competent to do your job?

Potential Answer/s:

  • When I was hired I attended a hospital orientation and a department/unit based orientation, as well as competency validation specific to my job. Additionally, I completed training through UMMS U, our learning management system (LMS).

Joint Commission Preparation: Tip of the Week

Something as simple as two different handwritings on a signature line can be interpreted as falsification of documentation. Such findings during a Joint Commission survey could result in an adverse accreditation decision.

In this example, Jane Doe, RN wrote in the date and time after Dr. Cdeghi signed the document.

During the Joint Commission Accreditation survey, when questioned Jane explained to the Joint Commission surveyor that she knew the document required time and date along with the signature. Jane thought she was helping.

If you encounter missing documentation, bring it to the attention of the provider and/or your supervisor

City of Cambridge, Dorchester County and the University of Maryland Shore Regional Health take step forward in future plans for health care facilities and services

Gathering in front of UM Shore Medical Center at Dorchester after signing the Letter of Intent which serves as a framework for future hospital property negotiations are (left to right): Dorchester County Council President Ricky Travers, Dorchester County Council member Don Satterfield, Cambridge Mayor Victoria Jackson-Stanley, and Ken Kozel, President and CEO of University of Maryland Shore Regional Health.

The City of Cambridge, Dorchester County and the University of Maryland Shore Regional Health took an important step forward in future plans for new state-of-the-art health care facilities and services in the county and a milestone in development of the Cambridge waterfront as a community asset and economic development engine.

On June 8, Mayor Victoria Jackson- Stanley, Council President Ricky Travers, and UM SRH CEO Ken Kozel signed a Letter of Intent (LOI) which, along with the Memorandum of Understanding (MOU) signed last month by the City and County creating a waterfront development entity, will serve as the framework for continued negotiations regarding the future sale and development of the current hospital property when the emergency department and outpatient services occupy a proposed new site in Cambridge. This move is anticipated by 2021, although that date is contingent upon local and State approvals in order to move ahead. The City of Cambridge and Dorchester County MOU created an entity, Cambridge Waterfront Development, Inc. (CWDI), which ultimately will purchase the current hospital property, prepare it for development, and negotiate its sale by the spring of 2021.

“The County Council is very excited to continue the working relationship with the City and we thank them for the opportunity to participate as a partner in this monumental place-making endeavor,” says Council President Ricky Travers. “We look forward to the completion of the CWDI board appointment process and we are excited about the direction this will take the waterfront for Cambridge. I was overwhelmed with the willingness of both the City and UM SRH to work as a team to guarantee success of this project,” Travers says.

Council member Don Satterfield adds, “This historic project and partnership is the product of significant effort from both City and County employees as well as the elected boards. It is a pleasure working with the City and I have full confidence that the project will be professionally managed and developed to its fullest.”

” We, as a community, are incredibly excited at the opportunity this provides the City and County,” states Mayor Victoria Jackson-Stanley. “The ability to combine the two land areas into one project, as well as the two primary governing entities working as one, create perfect alignment for a successful centennial project that will profoundly improve the viability of the Cambridge waterfront for years to come.”

While the LOI signed June 8 does not directly impact the health system’s required Certificates of Exemption (COE) application process, it does provide University of Maryland Medical System (UMMS) and UM SRH with an interested buyer, who shares the health system’s commitment and vision for a campus supporting the health care needs of people in Dorchester and neighboring counties, as well as the revitalization of Cambridge.
“We applaud the vision and leadership of Mayor Jackson-Stanley, President Travers and their councils,” says Ken Kozel. “It is our intent that through our shared process, we will reach agreement on the sale of our Cambridge property by the end of calendar 2018 and ultimately, transfer ownership of our property in the spring of 2021, when we anticipate re-locating our services to the new UM Shore Medical Campus at Cambridge.”

UM Shore Regional Health plans to initiate the regulatory approval process in July with the Maryland Health Care Commission. The health system will request converting the hospital to a freestanding medical facility, with a new, state-of-the-art emergency department and medical pavilion for needed health care services. Plans call for the facilities to be constructed on a new medical campus in Cambridge by 2021.