Twelve Clans Unity Hospital Achieves Monumental Step Toward CMS Certification

January 30, 2020

Twelve Clans Unity Hospital Achieves Monumental Step Toward CMS Certification

Winnebago, NE – On January 30, 2020, employees at Twelve Clans Unity Hospital gathered in a large conference room on the hospital’s third floor. Inside the room, consultants from Joint Commission Resources (JCR) took out their notes to begin briefing hospital staff. The purpose of this meeting? For the consultants to report their findings and critiques from a three-day intensive review of all the hospital’s internal systems, staff and policies.

JCR is an organization brought to the hospital by executive staff to evaluate the safety and quality of health care throughout the organization. The mission of the JCR’s visit was to perform a mock survey to determine Twelve Clans Unity Hospital’s readiness for an evaluation by Centers for Medicare and Medicaid Services (CMS). Results of this evaluation determine whether a healthcare organization meets applicable requirements for participation in Medicare/Medicaid programs and can become a certified CMS organization. When Twelve Clans ultimately achieves certification, it means that it meets the Social Security Act’s provider definitions and complies with health care standards required by Federal regulations.

“One three letter word for you…. WOW,” a JCR surveyor says as he turns his head in the direction of the hospital’s CEO, Danelle Smith. “Whatever you have done, what you’re working on, and how you’re doing it… it’s WORKING,” he exclaimed as he addressed the room of team leaders and staff. The general comments of impressiveness are echoed by the other three surveyors in the room. Most noteworthy was the statement of one specific JCR staff member who said that he had previously visited this same hospital three other times prior to Tribal assumption and had very noticeably seen a night and day difference in the facility.

Considering the short time since the hospital was assumed by the Winnebago Tribe - year and a half ago to be exact – the improvement is impressive. Prior to 2018, the hospital in Winnebago was operated by Indian Health Service (IHS). Back then, CMS had surveyed the hospital seven different times and reported multiple issues critical to the quality of patient care. Unfortunately, with each report IHS failed to make necessary corrections for patient safety and it ultimately led to termination of CMS certification in 2015. Quality healthcare in Winnebago had long been awaited by the community and it wasn’t until the Tribe created Twelve Clans Unity Hospital that the need began to be met.

Outside of the grand comments on the hospital’s practices and quality improvements, the JCR began to divulge their findings to hospital staff in greater detail. Most feedback consisted of minor suggestions for ways to improve a few specific health care practices. The hospital staff could be seen taking eager notes on the JCR’s recommendations – some even being implemented before JCR left the building that same day.

“You have a lot of quality people and it shows in your organization,” the surveyor concluded. It was clear that the staff made significant improvements throughout the organization.

So, what are the next steps? After implementing the feedback from JCR and confirming with CMS the category of certification for which the hospital qualifies, the hospital will fill out their CMS Certification application and go through the official unannounced survey. After the survey agency completes its assessment for the Medicare/Medicaid program, it submits evidence and a certification recommendation for a final CMS Regional Office determination.

Twelve Clans Unity Hospital has clearly made tremendous progress and CMS certification is within reach. In the meantime, the organization is committed to continuing its path to achieving and maintaining certification and providing quality health care for its patients every day.