May 4, 2018

WACH maintains high-level national accreditation, survey finds no clinical deficiencies

By Jo Garrison
Construction of the new Fort Irwin Weed Army Community Hospital at Fort Irwin, California, is more than 80 precent completed. A 7.6 acre photovoltaic (PV) array and a solar thermal array, will generate 2.4 megawatts of power and the solar thermal array will provide a majority of the hot water the hospital requires. The new hospital project consists of a 216,000 square foot hospital facility which will provide Soldier and family patient care, emergency medicine, and a wide variety of clinical support. Additionally, the project includes a 9,000-square-foot renovation of the Mary E. Walker Center and construction of a helipad, ambulance shelter, and central utilities plant. The facility stands to become the first LEED Platinum, net-zero, carbon-neutral hospital that will generate all of its energy needs from solar power and renewable energy systems.

FORT IRWIN, Calif. — The Joint Commission (TJC) visited Weed Army Community Hospital April 24 to assess the hospital’s quality of care following its recent transition to a new $211 million facility. The survey found no clinical deficiencies.

TJC is an independent, not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

Through the accreditation process, organizations also learn state-of-the-art performance improvement strategies in order to continuously improve the safety and quality of care, which can reduce the risk of errors.

The commission’s surveyors found no clinical deficiencies at WACH after completing an inspection of the maintenance and mechanical systems and walking through the operating rooms, emergency department, medical/surgical ward and mother-baby unit.

They did, however, point out five minor corrections needed to improve the facility.  These findings included incomplete documentation for the fire suppression system, small gaps in the smoke protection system, and a couple of preventive maintenance measures requiring action.  The hospital has six months to make the necessary corrections, but the leadership is confident that all corrections will be made within 30 days.

“For a brand new facility, I definitely expected to have some findings because we know we haven’t worked out all the kinks for the new hospital,” said Col. Martin Doperak, WACH commander.

The visit from TJC was an extension survey, not the full survey conducted triennially. It focused on infection control, the environment of care and life safety. The extension survey was required because at least 25 percent of the hospital’s services were relocated as a result of the move to the new hospital in September 2017.

The new hospital is a Leadership in Energy and Environmental Design (LEED) facility. It is certified by the U.S. Green Building Council as LEED Platinum, which is the highest level possible.  It is the third LEED Platinum hospital in the world and the first in the Department of Defense.

TJC will be visiting WACH again in February 2019 for the triennial survey, when a more extensive review of the facility will be conducted. That survey could last up to a week.

“Our goal is to maintain the level we reached because a lot of work went [into preparing for this survey] by many people to get us to the point where we pass Joint Commission with flying colors,” said Doperak.

Although TJC accreditation or certification is not mandatory, government facilities undergo the accreditation process to instill patient confidence by being completely transparent.  The process helps assure patients that the facility is measured by the same standards as civilian hospitals.

“By adhering to Joint Commission’s standards, what we are doing is setting a very high bar for ourselves to say that we are going to provide the best care possible to our patients, and that we are going to provide the safest care possible,” said Lt. Col. Katrina E. Walter, deputy commander for clinical services at WACH.

The results of TJC quality surveys are public information and can be viewed at

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