October 28, 2005

JCAHO lab survey successful

The September survey of the hospital's laboratory services by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was deemed successful by hospital leadership, as well as leaders from Pathology Services and Patient Care Services who were involved with this important inspection. A JCAHO surveyor made daily visits from Sept. 19 through Oct. 3, inspecting many areas involved with lab testing, including patient care units.

The MGH has received the lab survey results, which were largely positive but also identified specific areas that need improvement. Corrective actions now are taking place in those areas.

"We are very pleased with this survey — especially since this was the first time the lab surveyor used some of the new JCAHO survey procedures," says Donna MacMillan of MGH Pathology.

Because each day's inspection was unplanned and unannounced, staff from all areas were on alert for the surveyor's possible visits. The surveyor used the tracer methodology, a new process that assesses systems by "tracing" a patient's experience. She traced five patients during her visit, which took her to many areas of the hospital, such as the Operating Rooms to evaluate tissue banking, the cardiac intensive care unit to watch a transfusion performed and several patient care units to see how specimens were collected.

"All the staff on the units were phenomenal — everyone from the nurse managers to the front-line staff to employees in Pathology," says MacMillan. "The surveyor would observe procedures and then discuss issues with staff members, which could have been very intimidating for some employees. But everyone demonstrated the utmost professionalism. This inspection was a real team effort among many departments such as Nursing, the labs and the Safety Office."

The lab survey also provided valuable lessons to help hospital staff members further prepare for the hospitalwide JCAHO survey that will take place in 2006. "The lab survey gave staff an opportunity to showcase the work they do every day and be proud of their contributions to the hospital," says Maryanne Spicer, director of MGH Compliance and chair of the JCAHO Operations Committee. "We are always looking to improve in certain areas, and this survey highlighted some of the work we still need to do."

For more information about the 2006 hospital survey, visit the MGH JCAHO website at www.massgeneral.org/jcaho.