A Message from MGH President Peter L. Slavin, MD

April 20, 2007

Dear Colleagues,

At the Massachusetts General Hospital, we believe it is important to be as open and frank as possible, sharing information about what we are doing, what is going well and what we need to do better. We have been working hard to build a culture that values – indeed, celebrates – those who report errors or near misses because there is so much to learn from them. Our ultimate goal is to use all the information available to us to get better and better for the patients and families we serve.

In that spirit, I would like to share the results of our recent review from the Joint Commission. Virtually every hospital in the United States invites the Joint Commission to come in every three years to conduct an evaluation. Joint Commission surveyors assess an institution's performance on more than 250 standards, many of which examine quality and safety issues. In the past few years, surveys have become more focused, aiming directly at the quality and safety of the patient experience. Survey teams arrive at hospitals unannounced, and they use what is known as the tracer methodology to track, understand and review the course of care for a sampling of patients. The Joint Commission process traditionally has been a closed one, with findings available only to the surveyed hospital. Most facilities have chosen not to release their findings publicly.

The MGH underwent its Joint Commission review last December, with the survey team spending five days questioning, studying and evaluating our processes, policies and procedures. During the visit, surveyors noted areas of concern and prepared a report with their preliminary findings at the end of the week. Like all hospitals that undergo a survey, we were given an opportunity to respond to the Joint Commission's preliminary findings. We worked with Joint Commission staff to provide additional data where needed and clarify our policies and procedures so that the final report was a more accurate evaluation of our strengths and deficiencies.

On March 19, we received that final report from the Joint Commission. We were reaccredited, with the Joint Commission citing 10 areas requiring improvement, called RFIs. The MGH is a large academic medical center, and our Joint Commission survey results are comparable to other similar hospitals in the Boston area and nationally. That said, we were not happy with 10; in fact, we would not have been satisfied with seven or five or two RFIs. Our goal is zero. This week, we sent to the Joint Commission our action plan for addressing each of these RFIs, and we will closely monitor these areas to ensure we are not only improving and achieving compliance, but also excelling.

Since the founding of our hospital, dedicated men and women at the MGH have been working hard to strengthen and enhance all aspects of patient care, extending well beyond those areas in which we received RFIs. The Joint Commission's standards represent some of our industry's best practices, and hospitals should seize every opportunity to learn from their collective successes and shortcomings to promote safe, high-quality care. We hope other hospitals across the region and nation will release their Joint Commission findings as we are doing today. Sharing information honestly and accurately – whether it means taking bows or taking lumps – is essential if we are to constantly raise the bar on patient quality and safety.

Peter L. Slavin, MD
President
Massachusetts General Hospital