Friday, February 3, 2012

Joint Commission survey window opens


With the new year comes a new opportunity to showcase Excellence Every Day – the MGH’s commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations. The window for the MGH’s triennial Joint Commission survey has opened, and surveyors are expected to visit between now and August 2012.  The Joint Commission last visited the MGH in August 2009, and the survey report was excellent, with only two direct impact findings. This year’s goal is to complete the survey with no direct impact findings.

“We view the survey as a chance to demonstrate at a national level the commitment of MGH staff to Excellence Every Day,” says Peter L. Slavin, MD, MGH president. “We uphold the highest standards of quality and safety not because it is required but because it is the right thing to do.”

The 2012 survey will be very similar to previous ones. Six surveyors will notify the hospital of their arrival upon the first day of the survey. During the course of the five-day visit, the surveyors will visit patient care units and practice sites across the MGH and will be escorted by staff members at all times.

“Every MGH employee should expect to interact with a surveyor and be able to talk about his or her role in Excellence Every Day,” says John Belknap, director of Corporate Compliance. “If you have questions about what to expect during the survey, speak with your supervisor, department quality chair or call the Compliance Office at 617-726-5109.”

Throughout the coming months, the Excellence Every Day Communications Subcommittee – a subgroup of the
MGH Joint Commission Operations Committee – will be ramping up communications about topics that will
be key to a successful survey.   These topics include:

•  Knowing the top institutional performance improvement goals
for 2012;

•  Understanding that each and every employee has a role in the quality and safety improvement process;

•  Closely adhering to policies to reduce the risk of hospital-acquired infections, whether using proper hand hygiene or eliminating the presence of food and drink in patient care areas;

•  Ensuring appropriate management of medications, including reconciling patient medications in inpatient areas and ambulatory practices; and

•  Maintaining the safest possible environment of care for patients, for example, by keeping patient areas clear of unnecessary items or equipment.

Once the surveyors arrive, staff will be kept updated about the survey’s progress through hospitalwide communications. To learn more about ensuring Excellence Every Day for MGH patients and their loved ones, visit the recently redesigned website at                    

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