Accreditation

In our desire to provide the highest quality of care, VCU Health Community Memorial Hospital seeks accreditations from many professional organizations. The following accreditations are an achievement for CMH and acknowledge that we are following the best recommended practices in the heath care industry.

The Joint Commission

As proof of our organization-wide commitment to provide quality care, VCU Health Community Memorial Hospital voluntarily submits to review by The Joint Commission.  The Joint Commission (JC) conducts an accreditation survey of VCU Health Community Memorial Hospital. The purpose of the survey is to evaluate the organization’s compliance with nationally established JC standards. The survey results are used to determine whether -- and the conditions under which -- accreditation should be awarded to VCU Health CMH.

JC standards deal with organization and safety quality-of-care issues and the safety of the environment in which care is provided. VCU Health Community Memorial Hospital has achieved full three year accreditation from The Joint Commission (JC) as a result of its demonstrated compliance with their nationally recognized health care standards. This accreditation also includes CMH Home Health and Community Hospice, and The Hundley Center, Extended Care Facility.

As a patient, family member, community representative or employee of VCU Health Community Memorial Hospital, you have the right to notify The Joint Commission regarding any concern about the quality of care provided, safety of care provided, or safety of the environment in which care is provided. Anyone believing that he or she has pertinent and valid information about such matters should notify The Joint Commission.

Main Laboratory Accreditation

VCU Health Community Memorial Hospital Main Laboratory has been awarded an accreditation by the Commission on Laboratory Accreditation of the College of American Pathologists (CAP), based on the results of an on-site inspection. The CAP Laboratory Accreditation Program, begun in the early 1960’s, is recognized by the federal government as being equal to or more stringent than the government’s own inspection program.

During the CAP accreditation process, inspectors examine the laboratory’s records and quality control of procedures for the preceding two years. CAP inspectors also examine the entire staff’s qualifications, the laboratory’s equipment, facilities, safety program and record, as well as the overall management of the laboratory. This stringent inspection program is designed to specifically ensure the highest standard of care for the laboratory’s patients.

Vascular Lab Accreditation

VCU Health Community Memorial Hospital's Cardiopulmonary & Vascular Services has attained recognition for its commitment to providing a high level of patient care and quality testing for the diagnosis of vascular disease. VCU Health CMH has, yet again, achieved accreditation by the Intersocietal Commission for the accreditation of Vascular Laboratories (ICAVL). The ICAVL is a non-profit organization established with the support of eleven medical societies to provide a mechanism for accreditation of facilities, which perform comprehensive testing for vascular disease with noninvasive testing modalities. 

The Cardiopulmonary and Vascular Services Department at VCU Health CMH is one of a select number of vascular laboratories in the United States, Canada and Puerto Rico to meet or exceed the ICAVL standards for noninvasive vascular testing. During the accreditation process, every aspect of the laboratory’s daily operations and its impact on the quality of health care provided to patients is assessed and reviewed. Participation in the accreditation process demonstrates the laboratory’s attention to a high level of patient care and quality testing.

Echocardiography Lab Accreditation

VCU Health Community Memorial Hospital in South Hill has achieved accreditation for its Echocardiography Laboratory from the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL). The laboratory is one of the first one thousand echocardiography labs in the United States, Canada and Puerto Rico to be so recognized for its commitment to high quality patient care and its provision of quality diagnostic testing.

Participation in the accreditation process is voluntary. Accreditation status signifies that VCU Health CMH has been reviewed by an independent agency, which recognizes the laboratory’s commitment to quality testing for the diagnosis of heart disease.

Mammography Unit Accreditation (ACR)

VCU Health Community Memorial Hospital's Mammography Unit has been awarded a three-year term of accreditation in Mammography as a result of a survey by the American College of Radiology (ACR).

The ACR awards accreditation to facilities for the achievement of high practice standards after a peer-review evaluation of its practice. Evaluations are conducted by board-certified physicians and medical physicists who are experts in the field. They assess the qualifications of the personnel, adequacy of facility equipment, as well as quality assessment and improvement activities, including peer review. The surveyors report their findings to the ACR’s Committee on Accreditation, which subsequently provides the hospital with a comprehensive report.

The ACR is a national organization serving more than 32,000 radiologists, radiation oncologists and medical physicists with programs focusing on the practice of medical imaging and radiation oncology and the delivery of comprehensive health care services.

Mammography Unit Accreditation (FDA)

The Mammography Department at CMH has completed its an annual inspection and received certification by the Department of Health and Human Services, an arm of the Food and Drug Administration (FDA). Under the Mammography Quality Standards Act (MQSA), signed into law in 1992, all facilities that perform mammography must be certified by the FDA. Accreditation through the American College of Radiology (ACR) as well as successful results in the annual MQSA inspection are steps VCU Health CMH takes to assure patients and referring physicians that VCU Health CMH performs quality mammography, on quality equipment, by qualified, competent staff. 

To pass accreditation and subsequently qualify for a MQSA mammography facility certificate, a facility must meet stringent standards, which relate to personnel qualifications, equipment performance specifications, quality assurance, quality control testing, record keeping and how images are kept.