August 27, 1999

As part of the MGH's ongoing efforts to maintain high standards for all hospital operations, a "mock survey" was conducted in the ambulatory care areas Aug. 11 and 12. The goal of this mock survey and a similar one that took place in July is to identify improvements needed before the next hospitalwide visit from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the fall of 2000.

A consultant, contracted by the MGH, reviewed policies and procedures, interviewed staff and observed direct patient care for services such as Gynecology, Cancer, Dermatology and Neurology, as well as the MGH Chelsea HealthCare Center, some patient units and primary care practices.

"These mock surveys provide a good opportunity to see ourselves through the eyes of others," says Maryanne Spicer, director of Corporate Compliance. "They give us the chance to assess our state of readiness and to practice for external review by the JCAHO surveyors."

The Greeley Company, the consulting firm that performed the July mock survey, has reported back recommendations for such improvements as refining patient and family education on details of care, improving patient documentation and increasing use of employee performance evaluations hospitalwide.

Recently, the JCAHO has changed its surveying policies in response to intense public scrutiny of the organization's accreditation process. Significant changes include:

* There will be no advance notice to hospitals for random unannounced surveys.

* Random surveys will be conducted any time from nine to 30 months after the routine survey every three years.

* The focus of surveys will be tailored to each organization and will depend on previous survey findings and other information.

The next JCAHO survey for all MGH sites involving clinical testing has been scheduled for Sept. 7 to 10 (see What's Happening announcement).

For more information about the JCAHO survey process, call Corporate Compliance at 6-5109.