February 17, 2006

JCAHO readiness continues: Unannounced survey in 2006

Ongoing readiness efforts continue for the upcoming survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which will take place some time in 2006. As of Jan. 1, the JCAHO has adopted a new policy of unannounced visits to health care organizations, which means that hospitals such as the MGH can expect the JCAHO surveyors to arrive at any time without prior notice.

"This new policy will allow the Joint Commission to be an unbiased reviewer of compliance with its standards," says Maryanne Spicer, director of MGH Compliance and chair of the hospital's JCAHO Operations Committee. "The Joint Commission also wants to encourage hospitals to sustain ongoing compliance — not to just ramp up their compliance activities when they know they will be surveyed. We support this approach and work each day to sustain and improve our performance and compliance with JCAHO standards."

As a part of these ongoing performance evaluation and readiness efforts for the JCAHO survey, the hospitalwide FYI campaign continues to keep employees and staff aware of important information related to their roles and responsibilities within the MGH community. The campaign — which features posters, flyers and articles in hospital publications — is meant to help MGHers provide the highest quality of care to patients while meeting the standards set by JCAHO.

The most recent FYI poster (shown above) was distributed throughout the hospital this past week to remind MGHers of the performance improvement method the hospital has adopted called Plan, Do, Check, Act.

Performance improvement — the practice of measuring patient care performance and looking for ways to do it better — is at the foundation of the MGH's mission to provide the best patient care. While the MGH has embraced performance improvement methods throughout its history, the hospital adopted the Plan, Do, Check, Act method as a simpler way of describing this approach. The method consists of four continuous steps:

Plan: Identify an opportunity for improvement, measure current performance, set goals and develop an improvement plan.
Do: Implement improvement plan by identifying resources and piloting the solution.
Check: Measure performance again to see if the plan worked.
Act: Standardize the process and monitor to sustain improvement.

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