The MGH is now reviewing and addressing the findings from the Joint Commission’s latest visit, part of its recent laboratory program reaccreditation survey. The organization’s three surveyors – consisting of two medical technologists and, for the first time during a survey visit to the hospital, a pathologist – arrived at the MGH July 15 for a weeklong visit.
“As usual, the surveyors were extraordinarily impressed with the engagement of our staff and said we were very welcoming and friendly,” said Patrick Adams, RN, senior specialist in Clinical Compliance at the MGH. “Although this was a lab survey, it really was a hospital-wide assessment because the lab’s services are so integrated into nearly every operation within the hospital. The surveyors said, as they have in the past, that we were accommodating and honest during their visit. And they really couldn’t say enough about the clinical care that they witnessed. Every time they looked at the delivery of patient care, they were very impressed and complimentary.”
However, surveyors did note that improvements need to be implemented in a few areas, mainly within clerical and administrative functions. “There are areas where we need to do a better job with verifying the work we have done,” said John Belknap, director of Corporate Compliance. “For example, each machine has a scheduled calibration; however, written confirmation of this calibration was not documented. Our systems used to verify completion of this work need some improvement.”
Another example of a system requiring improvement was documentation to support blood transfusion. The surveyors observed a transfusion and commented that the clinical care was excellent – however, the documentation specifics required for transfusion were not consistently located by the survey team.
In response to these findings, members of the laboratory compliance team are working closely with Patient Care Services and the Center for Quality and Safety to ensure that a proper and sustainable corrective action plan is immediately put into place. These plans will then be sent to the Joint Commission by mid-September. “While all of the areas that need improvement will be addressed, select findings may warrant a more detailed quality improvement assessment in order for us to make sure we not only fix the problems now but also prevent similar occurrences in the future,” Adams said.
The MGH’s next combined Joint Commission reaccreditation survey for both the hospital and the laboratory programs is scheduled for 2015.
Read more articles from the 08/02/13 Hotline issue.