[B]RATTLEBORO – The Brattleboro Retreat has been reaccredited for the next three years, and administrators say it’s yet another sign that the hospital has recovered from past regulatory troubles.
The Joint Commission, an Illinois-based nonprofit that surveys thousands of health care organizations nationwide, examined Retreat operations in late October and granted its “gold seal of approval.”
Hospital administrators say the Joint Commission’s “rigorous” survey and subsequent recertification highlight their continuing efforts to improve the facility’s mental health and substance abuse treatment programs.
“What it shows is that we’ve worked very hard in focusing our attention on developing a new approach to patient care,” said Kirk Woodring, the Retreat’s chief clinical officer.
The Retreat employs nearly 900 people and plays a key role in the state’s addiction and mental health treatment system. The hospital took on an even greater role after Tropical Storm Irene’s flooding closed the Vermont State Hospital in 2011.
But the Retreat then ran into numerous serious regulatory issues that jeopardized its governmental funding and raised questions about patient safety.
In fall 2014, the Retreat and the Centers for Medicare and Medicaid Services entered into a systems improvement agreement that allowed the hospital to continue to operate while administrators addressed regulatory concerns.
Reaccreditation from the Joint Commission, which dubs itself “the nation’s oldest and largest standards-setting and accrediting body in health care,” could be seen as another step in the Retreat’s recovery.
President and Chief Executive Officer Louis Josephson, who took over as the Retreat’s top administrator in early 2016, said reaccreditation is “a meaningful achievement in a process of ongoing quality improvement that never really ends.”
When viewed in context of the issues the Retreat faced several years ago, “it’s a significant turnaround to go from significant regulatory jeopardy to an outstanding review,” Josephson said.
Josephson said the Joint Commission focused on “clinical quality and patient safety” and the review produced no “condition-level findings” – meaning serious findings that could have landed the Retreat in regulatory trouble.
“The other ones were relatively minor, and we’re addressing those,” he said. “It’s just a big relief, and it’s a great credit to the staff.”
Woodring said the commission’s review, which included a site visit Oct. 24-27, was “really a full look at the entire organization.” He said evaluators noted the Retreat’s recent implementation of two new treatment models that required retraining staff.
“We were really praised for having used evidence-based (treatment) practices,” Woodring said.
Other issues evaluated by the Joint Commission included the Retreat’s care environment; leadership; and “screening procedures for the early detection of imminent harm,” administrators said.
The commission’s three-year certification doesn’t mean the Retreat will be free from scrutiny for several years.
CMS and state regulators can examine the hospital at any time and order improvements, as happened last year in the wake of a patient’s suicide less than 24 hours after leaving the Retreat. The hospital changed its admission and discharge practices in response.
