April 1, 2005

MGH scores well in performance review to prepare for JCAHO survey

Since the fall, the MGH has begun preparations for the next survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which is expected to take place some time in 2006.

The hospitalwide JCAHO operations steering committee recently completed a Periodic Performance Review (PPR) and submitted the results to JCAHO. The PPR is an internal analysis that rates a health care organization's compliance with JCAHO standards and is usually conducted at the midpoint of the accreditation cycle to allow an organization to make improvements.

The results of the MGH's PPR show that the hospital is compliant with 230 JCAHO standards and needs to correct 10 areas rated as noncompliant. Some of the areas that need improvement include pain management, information systems disaster recovery, unsigned verbal orders, use of patient identifiers, critical results reporting and medication reconciliation.

"This self assessment is a valuable tool to help us focus on areas of improvement long before the JCAHO survey actually takes place," says Maryanne Spicer, director of Compliance and chair of the JCAHO operations steering committee. "While only 10 standards scored as noncompliant, the assessment also revealed several areas needing minor improvement or clarification. This internal look at hospital operations is an important opportunity to identify learning needs and policy and practice enhancements in a sufficient amount of time to be well prepared for the actual survey."

For more information about the JCAHO survey, contact Spicer at (617) 726-5109.