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Six surveyors from the Joint Commission will arrive unannounced at the MGH any time between now and August to visit a wide range of patient care units and practice sites during the course of their five-day survey.

Performance improvement initiatives at the MGH

09/Mar/2012

 

Six surveyors from the Joint Commission will arrive unannounced at the MGH any time between now and August to visit a wide range of patient care units and practice sites during the course of their five-day survey. In preparation for this visit, the MGH has identified four key performance improvement initiatives aimed at ensuring the quality and safety of care for patients.

Medication reconciliation: This includes collecting and documenting a complete list of medications for each patient. For ambulatory visits, the medication list is to be updated at each visit, and any medication changes must be reconciled with the list. Patients should also receive copies of their reconciled medication list to review and keep for their records.

Universal protocol: This process ensures the correct patient is receiving the correct procedure on the correct site for all operative and invasive procedures. The three components of the universal protocol are pre-procedure
verification, procedural site marking and hard stop time-out.

Infection Control: This refers to reducing health-care-associated infections through excellent hand hygiene before and after patient contact and using the appropriate personal protective equipment.

Care Redesign and Innovation Units: These efforts to rethink the processes of care delivery at the MGH and to improve quality and efficiency are moving forward with promising results. To date, care redesign teams have focused on colon cancer, coronary disease – including acute myocardial infarction and coronary artery bypass graft – as well as diabetes, primary care, stroke, vaginal delivery, lung cancer, endovascular procedures, transplantation and total joint replacement. Some teams are now beginning to design and test specific interventions that they identified through this recent analysis to improve quality and decrease costs. Care redesign will be
the MGH’s most important institutional initiative for the foreseeable future.

To learn more about Care Redesign and Innovations Units, access
http://priorities.massgeneral.org/home.aspx.

To learn more about ensuring Excellence Every Day, access
http://intranet.massgeneral.org/excellenceeveryday.

Assessing MGH’s culture of safety
Later this month, the MGH community will be asked to assess its culture of patient safety – an environment in which all employees feel safe reporting errors and near-misses
and, most importantly, are working to improve the quality of care offered to patients. MGH staff whose work directly affects patient care and who work at least 20 hours per week will be contacted via email to complete a brief survey with questions about the safety of the environment provided to MGH patients. The questions will address topics such as teamwork within and across units, nonpunitive safety event reporting and learning from errors.  All answers will be logged anonymously. The results will help tailor patient safety efforts to have
the greatest impact and provide a baseline against which to assess future policies and programs.


Read more articles from the 03/09/12 Hotline issue.

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