September 29, 2000

Michael Sills of Blake 11 seemed a little nervous sitting next to the surveyor from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) last week. He wasn't sure how to respond to the surveyor's question: "What do you call this seat next to me? Is it warm?" He responded: "Well, I guess we can call it the hot seat." Everyone in the room laughed.

Sills and the rest of the Blake 11 staff were surprised and relieved that the surveyor, Joanna Magdo-Polenz, MD, used a sense of humor to break the tension during what is considered one of the most intense visits from an outside organization the hospital experiences. Like many hospitals around the country, the MGH invites the JCAHO to review all hospital programs and facilities because many third-party payors such as Medicare require JCAHO accreditation for participation.

MGHers at work under the watchful eyes of JCAHO surveryors during the recent inspection.

Ultimately, the Blake 11 inspection went well. Magdo-Polenz, who also is a practicing psychiatrist, toured the unit and then met with an interdisciplinary team of caregivers. She asked tough questions about adverse drug reactions, the environment of care standards, the use of restraints on patients and performance improvement efforts. Magdo-Polenz also reviewed a randomly selected patient chart and asked several staff members about this particular patient's plan of care. This same scenario played out on other inpatient units and in the ambulatory areas during the week.

Despite the anxious anticipation among staff and employees, many MGHers felt that the inspection was a constructive educational experience. "It really is a good opportunity to hear staff talk about what they do every day," said Bonnie Glass, RN, associate chief for Patient Care Services, who helped escort some of the surveyors to the units. "We rarely have an opportunity to spend an entire week evaluating our processes. It really has been powerful. The work our staff does is so good and is at such a high level. It has been gratifying to see it firsthand in this kind of forum."

James J. Mongan, MD, president of the MGH, said that the hospital had a very strong performance during the course of the week. "In many respects, it was our strongest survey ever," he said. "I am most grateful to the many employees who have worked very hard to prepare for this survey. I particularly want to acknowledge the dedication of Maryanne Spicer [director of MGH Compliance], who along with the hospital's JCAHO steering committee led the comprehensive efforts in preparing for the survey."

According to a preliminary report from the JCAHO surveyors, the MGH had only one major citation – the fewest it has ever received. This citation relates to the documentation of credentials for one practitioner. The hospital soon will receive the final JCAHO report.

"I am continually impressed by the dedication of all employees throughout this organization who are committed to providing the best possible care to our patients," said Spicer. "The survey lets us showcase our employees' hard work, and it gives them an opportunity to really shine."