Staying Prepared: How JPS Achieved Zero EVS Findings Across 28 Hospitals

When the Joint Commission (TJC) surveyors arrived at JPS (John Peter Smith) Health Network to conduct their accreditation review, they were met with an extraordinary sight—28 clinics and a 600-bed hospital functioning at peak efficiency with zero environmental services (EVS) findings. But what does it take to hit such a high mark, and why does it matter so much?

To unpack this, we spoke with Dewayne Kirksey, a Vice President at HHS, who shared insights into the culture, processes, and leadership style that made this possible.

Why Zero Findings Matter

The Joint Commission accreditation survey is a key event for any healthcare organization. Held every three years, the survey assesses whether a facility meets the standards required to continue providing care. “Failing accreditation could have serious consequences, including shutting down services,” Dewayne explains.

What makes our JPS team’s accomplishment remarkable is the scope of their 2024 survey. Unlike previous years, this year’s survey included all 28 clinics and the main hospital—an additional 23 locations where issues could have been found. This expansion meant that the opportunities for findings were far greater, yet they came through with zero findings across the board. This is a testament to their robust culture of excellence.

Always Prepared: The Key to Success

“The secret,” Dewayne says, “is not about getting prepared but staying prepared.” With no advance notice of the surveyors’ arrival, the team relies on daily practices and consistent standards. At HHS, being “Joint Commission-ready” isn’t a last-minute scramble; it’s a way of life. Safety huddles and monthly in-services play a key role in staying prepared. These meetings go beyond routine check-ins—they’re a chance to review processes, track quality metrics, and focus on areas for improvement.

“You can’t just check a box,” Dewayne emphasizes. “Each day matters, and every conversation in these moments has to carry weight.”

The Role of Strong Leadership

Success isn’t just about strong processes—it also needs adaptive, effective leadership. Dewayne credits his leadership’s teamwork and ability to recognize and build on each other’s strengths, especially from key members at the director level. He specifically praises Latrice Manlove, Brian Cotton, and Gabriela Rangel for their ongoing efforts to promote accountability and high standards.

“When you have that many leaders on-site, everyone has different strengths and weaknesses. My role is to recognize those and ensure we support each other,” he explains. For example, one leader might excel at leading engaging safety huddles, while another shines in operational oversight. By combining their strengths and supporting each other, every part of EVS operations is covered.

As Dewayne puts it, “If you let one thing slide—like not mopping under a bed—it can snowball into a department-wide issue. Consistency is key.”

Unprecedented Recognition

During the survey, a TJC surveyor made a rare request to attend an EVS team huddle—a moment Dewayne noted he had never seen before in his career. The surveyor praised their key role in stopping infections and keeping the space clean, safe, and healing. Dewayne reflects, “It was huge for our team to see that their work isn’t just about cleaning rooms; it’s about making a real impact on patient care and safety.”

High Standards, High Impact

The team’s approach leaves no room for oversight. EVS audits are thorough and happen often, with any issues being handled right away. “You have to be willing to address issues every single day,” Dewayne shares. “That mindset drives our results.”

This steady focus on quality has created a culture where excellence is celebrated. From housekeepers to department leaders, everyone contributes to upholding these high standards.

Why This Matters

Beyond the recognition, the zero-findings result across all 28 hospital locations sends a strong message to patients and stakeholders. Dewayne explains, “When you achieve results like this, you’re telling your customer that their trust and investment were well-placed. It’s not just about a clean hospital—it’s about creating a place where healing can happen.”

A Model for Success

This achievement showcases the incredible impact of strong leadership and consistent processes. It’s a powerful reminder of the vital role EVS teams play in healthcare and the difference they make in patient care every day. As Dewayne aptly puts it, “Every day matters. When you approach each day with that mindset, results like this aren’t just possible—they’re inevitable.”