The window for the MGH’s triennial survey from The Joint Commission is open, and surveyors will arrive unannounced at any time between now and April 2018. During their week-long review, the team will visit several areas within the hospital, including inpatient units, ambulatory practices and procedural areas.

The Joint Commission is a nonprofit organization that accredits most hospitals – including the MGH – in the United States and sets standards for accreditation that allows institutions to continue to participate in government-paid insurance programs and private payer programs.

“Although we do not know when surveyors will arrive, we must continue to always practice Excellence Every Day in preparation for their visit,” says John Belknap, chief compliance officer. “The MGH is always working to identify quality and safety issues and ways in which we can strengthen those areas. We ask staff to pay careful attention to the area in which you work and, as always, we thank you for performing your job with Excellence Every Day.”

Staff should review the following five things as the hospital prepares for The Joint Commission’s visit:

Know the fire prevention and response plan. Staff should know where fire extinguishers and alarm-pulls are located. They should familiarize themselves with RACE (Rescue-Alarm-Confine-Extinguish/Evacuate) and PASS (Press-Aim-Squeeze-Sweep).

Follow all storage rules:

Gas cylinders should be secured in holders in designated locations. Keep full and empty cylinders separate. Make sure all oxygen is kept at least 5 feet from combustible materials.

Know where the gas shutoff valves are. Valves must always be accessible. Make sure shutoff valves are not blocked.

Keep all material 18 inches from sprinklers. All regular storage must be kept 18 inches or more below the level
of sprinklers.

Keep corridors clutter free. All items in hallways must be on wheels and off to one side. Service carts must be attended and in-use. Never prop or wedge doors open.

Know about chemicals. Staff should use all chemical materials as they are intended, following all training guidelines. They should consult product labels for hazard warnings and precautions and review safety data sheets for more product detail. These Material Safety Data Sheets are available in
the Partners Applications Menu,
under Utilities.

Report any utility issues to Buildings and Grounds. Issues with electrical service, elevators, call lights, pneumatic tubes, plumbing, steam, water and heating/cooling systems should be reported to Buildings and Grounds at 617-726-2422.

Know what keeps you safe. Staff should know the MGH has a
state-of-the-art, integrated security system that uses dual-technology ID badges, closed circuit cameras, panic buttons, card readers and other special locking devices, voice/video intercom systems and infant protection systems.

For more information visit the Excellence Every Day intranet site at:

Read more articles from the 11/10/17 Hotline issue.