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Massachusetts General Hospital
Summary of the Joint Commission Findings

Updated 15 October 2008

If you have any questions or comments about the Joint Commission survey or the findings, please contact Gregg Meyer, MD, MGH/MGPO senior vice president for Quality and Safety at gmeyer@partners.org, (617) 724-9194; or John Belknap, MGH director of Corporate Compliance at jbelknap@partners.org, (617) 726-5109.

Requirements for Improvement

1.)        PC 8.10 – Pain is assessed in all patients

  • A comprehensive pain assessment is conducted as appropriate to the patient’s condition and the scope of care, treatment and services provided.
  • Regular reassessment and follow-up occur according to criteria developed by the hospital.

What did the Joint Commission find?

During the December 2006 visit, Joint Commission surveyors found that documentation of pain assessment was inconsistent in several of the patient records they reviewed. In a few cases, the assessment of pain was delayed by one hour or several hours. In some cases the documented intervals for reassessment of pain were either longer than hospital policy directs or a particular reassessment in a series was not documented. 

Why is this important?

Pain is a very subjective measure; nonetheless, it is a vital tool both in diagnosis and response to treatment. It is essential for the patient to be a partner in understanding and reporting pain, and it is essential for the clinician to be a partner in helping the patient alleviate unnecessary pain. Only through careful monitoring and communication can this important relationship be as effective as possible. While it appears that assessment and reassessment of pain does indeed occur regularly and routinely at the hospital, documentation of this activity needs to be more consistent.

What are we doing about it?

The MGH has carefully reviewed its policies to clarify and simplify the requirements for assessing and reassessing pain. With the help of many people at the hospital, we have reduced what was a complex 23-page document outlining the process and procedures for pain assessment and reassessment down to two pages. In addition, all staff members have received reminders about the specific details of this requirement. Units are self-monitoring weekly.  Also, the MGH Quality and Safety Program has undertaken independent audits of pain assessment and reassessment to ensure compliance.

Where are we now?

Our baseline data indicate that we had been meeting the required documentation elements of this standard about 50 percent of the time.   Compliance has improved dramatically, and in September of 2007, measured 95% for pain assessment, and 90% for pain reassessment.  We will continue to monitor these areas closely to ensure that they also continue to improve.

 

2.) PC 11.70 – Patients in restraint are monitored

  • A patient in restraint is monitored at least every two hours or sooner according to need and hospital policy.

What did the Joint Commission find?

When the Joint Commission was reviewing the use and documentation of patient restraints, a surveyor found that one patient’s restraint flow sheet had a gap of six hours in documentation for monitoring. The requirement is for two-hour regular checks.

Why is this important?

The failure to closely monitor patients who are in restraints can be associated with risk of injury to the patient.

What are we doing about it?

The patient restraint policy and procedure is long, detailed and complicated. Documentation expectations are extensive and at this time entirely manual after the patient order is initiated. Extensive flow sheets are used to record detailed observations.  It is clear that detailed documentation cannot be eliminated in this vulnerable population and so the approach here has been awareness raising and clarification of the important benchmarks of complete documentation. Tools have been developed and circulated to all nursing staff to explain clearly the specifics of documentation required. The Office of Quality and Safety continues to closely monitor the use and documentation of restraints.  The best solution to these extensive documentation requirements is an electronic system that would make full documentation immediate and clearer for the clinician.  Current plans include automation of various aspects of nursing documentation although there is a substantial queue of highly desired record elements to be accomplished.

Where are we now?

Results from monitoring have shown a steady improvement, in all elements of ongoing monitoring, including documentation of every two-hour monitoring. At baseline, compliance often hovered around the 50 percent level.

 

3.) NPSG 7 – Reduce the risk of health care associated infections

  • Comply with all current Centers of Disease Control and Prevention hand hygiene guidelines.

What did the Joint Commission find?

Joint Commission surveyors observed three occasions during the review in which radiology technologists did not disinfect their hands after positioning the patient and touching equipment.

Why is this important?

Infection is a widely known complication that can be substantially reduced if basic infection control strategies, such as regular hand hygiene practices, are used by every person who comes into contact with patients.

What are we doing about it?

Infection control specialists have evaluated the specific needs in the radiology environment related to hand hygiene. Protocols for hand hygiene and additional training have been provided to staff in this area. In addition, the MGH continues to communicate extensively about the importance of hand hygiene and has made Cal Stat readily available throughout the institution.

Where are we now?

Over the past several years, the MGH has seen very real improvement in hand hygiene practices.  In 2002, our compliance rates in all hospital units hovered around 50% after patient contact, and 10% before patient contact.  In the second quarter of 2007, these rates had improved to 86% before patient contact, and 78% after patient contact.    By November 2007, we had achieved 90% before contact, and 92% after contact. During the 2nd quarter of 2008, our performance was 89% before contact, 94% after contact, and in several months during 2008, we scored above 90% both before and after contact.  Given its importance to patient safety, we continue to monitor our performance closely and hold ourselves to a very high standard.  We encourage you to visit our quality and safety website for additional information on our performance and our hand hygiene program – http://qualityandsafety.massgeneral.org/measures/hygiene.aspx?id=282 

 

4)

  • IM 6.10 – The hospital has a complete and accurate medical record for patients assessed, cared for, treated or served.
  • Medical record entries are dated, the author identified, and when necessary, according to law or regulation or hospital policy, authenticated by written signature, or computer key or rubber stamp.

What did the Joint Commission find?

Surveyors in December 2006 found that three of the medical records they looked at contained an entry that did not have an exact time of day listed. They also found two records that had an entry that was not dated or timed.

Why is this important?
 
Precise dating and timing of clinical events documented in the medical record can be essential to understanding the clinical course of a particular patient and can provide important insights into the specific point of time when the patient’s condition or symptoms changed for the better or worse.

What are we doing about it?

In the next few years, we will be introducing electronic medical records to all of our patient care areas, and this system will automatically date- and time-stamp all entries. Until that time, however, we must address this deficiency in our paper records.  We have had extensive education related to date- and time-stamping all entries for providers, and this effort has included presentations, newsletters, email messages and discussions with clinical leaders to raise awareness. In addition, we have begun systematic audits of samples of inpatient charts to look for dates and times. When a date or time is not found, the responsible clinician is contacted to correct or amend the note. Effective in April 2007, hospital charts are considered incomplete until the dates and times are included in every entry. Clinicians whose charts are incomplete for a specific number of days will have their admitting privileges suspended until all charts are completed.

Where are we now?

We are continuing to monitor our progress on this important documentation issue, and we have seen a significant improvement since we began the education and auditing process.    In September 2007, our compliance reached 94% with dating and timing of notes.  Recent quarterly audit data (June – August 2008) showed we were performing at 98% with dating of records, and 90% with timing of records.  Audits are being conducted on an ongoing basis.

5)

  • MM 2.20 – Medications are properly and safely stored
  • Medications are stored under conditions suitable for product stability.
  • Unauthorized persons in accordance with the hospital’s policy and law and regulations, cannot obtain access to medications.
  • All expired, damaged, and/or contaminated medications are segregated until they are removed from the hospital.

 

What did the Joint Commission find?

The Joint Commission surveyors identified various issues with medication storage and transport in various sites they reviewed.  Most of the issues involved access to medications, such as medication kept in a refrigerator that could not be locked, medication in a drawer that could not be locked and nonclinical staff being able to go into medication storage areas.  Surveyors also observed three cases in which the expiration date on a drug had passed.

Why is this important?

Storage and security of medication pose great challenges for hospitals given the use of pharmaceutical products in virtually every phase of a patient’s care. Proper storage of medications requires multiple practices and strategies to ensure safety. Medications stored in areas that have limited access and layers of security, such as the operating rooms, are likely less vulnerable than medications that are stored in exam rooms of busy office practices. All medication storage areas, however, must be appropriately secured with access limited to only those who are authorized.  To maintain and ensure effectiveness of medications, proper storage also requires ongoing documentation of temperature in refrigerator units and regular checks of expiration dates. 

What are we doing about it?

Each circumstance of improper storage that could compromise the effectiveness of a drug was corrected immediately. To ensure closer oversight moving forward, unit pharmacists are using a variety of tools, including monitoring and spot-checking of medication logs and medication refrigerator use and using audit tools from drug storage systems to more closely monitor approaching expiration dates.  Regarding issues related to access to medications, job descriptions have been revised to clear up any questions about specific roles and positions and their authorization to such storage areas.

Where are we now?

Monthly pharmacy quality rounds have recently been implemented to offer an independent review of medication storage issues and track progress in this area. The Medical Staff Medication Oversight Committee will monitor this work and address any unresolved problem areas. In addition, the hospital is looking at several new types of storage systems for bulk intravenous solutions, with plans to install a system this summer.  Leadership in the MGH Pharmacy is developing a concise set of principles regarding storage and security of medications in different types of practice settings, and these principles will be communicated and applied by responsible professionals in these settings. .  Recent monthly audit data (August 2008) indicated that logs were in place 99% of the time, and that virtually none of the areas audited had expired medications.

6)

  • NPSG8 – Accurately and completely reconcile medications across the continuum of care.
  • Implement a process of obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient.  The process includes a comparison of the medications the organization provides to those on the list.

 

What did the Joint Commission find?

The Joint Commission surveyors observed three cases in which there was no indication that the pre-admission medication list (PAML) process had been completed as required. The MGH’s electronic system of medication reconciliation was not being used consistently across patient care units. 

Why is this important?

Medication reconciliation is a process in which the medications a patient is taking at home or in a previous health care setting are checked against the medications ordered in the hospital or new care setting. This process is essential to medication safety. Research has shown that transitions between care settings represent significant opportunities for error that have been linked to patient harm.

What are we doing about it?

In January 2007 the MGH’s electronic medication reconciliation system was enhanced to facilitate the generation of accurate computerized medication orders. Shortly thereafter a “hard stop” was introduced in the system requiring the completion of a pre-admission medication list prior to discharge from the hospital. Progress will continue to be monitored, and if medication reconciliation goals of 90 percent of patients having their medications reconciled within 24 hours of admission have not been met, a hard stop at 24 hours will be introduced which will not allow orders to be entered into our electronic order entry system without a completed PAML.

Where are we now?

Since the introduction of the electronic medication reconciliation system and the hard stop at discharge, medication reconciliation rates have improved significantly.    In late June, compliance with medication reconciliation within 24 hours of admission improved to 74%, but has plateaued in recent months.  Because we missed our original goal of 90 percent, we introduced a hard stop within 24 hours of admission in late July 2007.  Recent quarterly data (June – August 2008) indicated much improved compliance – 91% of medications were reconciled within 24 hours, 97% within 36 hours, and 97% upon discharge.

7)

  • EC 7.50 – The hospital maintains, tests and inspects its medical gas and vacuum systems.
  • The hospital maintains, tests and inspects critical components of piped medical gas systems including master signal panels, area alarms, automatic pressure switches, shut-off valves, flexible connectors and outlets.

What did the Joint Commission find?

The survey team observed that some medical gas alarms had not been tested monthly.

Why is this important?

Medical gases are an essential part of patient care – the hospital has an extensive physical infrastructure in place to deliver those gases to the bedside. This infrastructure requires careful and ongoing monitoring to ensure safety.

What are we doing about it?

Immediately following the December survey, a complete inventory and inspection of these unit-based alarm panels was conducted. One nonperforming alarm was repaired. The panels will now be a routine part of the monthly maintenance rounds conducted by Buildings and Grounds staff to ensure proper performance of the alarm system.

Where are we now?

Staff members are implementing an ongoing testing plan for the alarm panels throughout the hospital On a monthly basis, the MGH inspects over 1200 fire extinguishers and over 100 alarm panels.  .  By July 2007, 102 panels have been tested, and 7 repairs have been made to 4 alarm panels.  In September 2008, no repairs were required to either fire extinguishers or alarm panels. 

8)

  • UP 1 – The hospital fulfills expectations set forth in the Universal Protocol.
  • Conduct a pre-operative verification process as described in the Universal Protocol
  • Conduct a “time out” immediately before starting the procedure as described in the Universal Protocol.

What did the Joint Commission find?

In several areas outside the operating room where procedures, such as central line insertion, are performed, there was no evidence in the patient record that safety checks had been performed to confirm the correct patient identity and the correct procedural site.

Why is this important?

The “Universal Protocol” involves a series of steps to confirm the site of a procedure or a particular medical intervention in each individual patient. Taking a “time out,” during which all team members come to a full stop, discuss the planned procedure and confirm that the right patient is having the specific procedure performed on the appropriate procedural site, is a key step in avoiding wrong-site surgery.

What are we doing about it?

The MGH has developed a specific tool to assist in documentation of Universal Protocol, and the tool is being deployed throughout practice areas. This tool incorporates the documentation of the “time out” check with the form that documents consent. It provides for a standard format and location in the medical record. In addition, an oversight committee has been formed and charged with the task of standardizing an approach to the Universal Protocol in non-operating room areas.

Where are we now?

As much as we have done and continue to do to be compliant with this important standard, challenges remain outside of our main operating room.  During 2008, there were three incidents at the MGH in which the incorrect application of the universal protocol partially contributed to patients having either an injection delivered to the incorrect site, or having an incorrect minor procedure performed.  None of the patients in these cases suffered a serious injury, nor do we anticipate any long-term adverse health consequences for the patients.  All three incidents were immediately disclosed to the patients involved, and reported to the Massachusetts Department of Public Health.  We take these kinds of events very seriously, and addressing this issue is one of our top priorities.

Baseline evaluations have been performed on compliance with universal protocol.  Our most recent audit, completed in July 2008, indicated 84% compliance with the elements of documentation of the universal protocol.  We have launched a comprehensive campaign re-educating our staff about when the universal protocol applies, how to properly perform it, and how to document it.  Auditing activity on both the performance of the protocol and its documentation will continue.

9)

  • EC 5.50 – The hospital develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code.
  • Each hospital implements ILSMs as defined in its policy.

What did the Joint Commission find?

At a community hospital where the MGH operates a specific program in leased space, a construction project was under way immediately outside an emergency exit.  A hole had been dug at the construction site, which was interfering with the operation of the emergency exit and creating a potentially unsafe situation. 

Why is this important?

Construction and other environmental changes can impact patients, families, visitors and staff adversely if proper hazards are not evaluated and mitigated.  Special care must be taken to protect patient populations that are particularly vulnerable to exposure to environmental hazards or when the ability to evacuate to safe zones may be compromised.

What are doing about it?

Landlords are required to inform the hospital of construction projects to enable the MGH to perform a safety analysis and institute additional equivalencies to protect occupants.  To ensure that the hospital is aware of such projects, an MGH safety officer has been assigned direct responsibility for off-campus sites and will maintain a quarterly communication mechanism to inquire about upcoming plans and evaluate safety readiness.

Where are we now?

This ongoing communication program related to off-site plans and safety readiness has been implemented.  The MGH Safety Office checks with offsite locations quarterly to determine if there are any construction projects requiring an assessment, and conducts site visits on an as needed basis.

10)

  • RI 2.80 – The hospital addresses the wishes of the patient relating to end-of-life decisions.
  • Documentation indicates whether or not the patient has signed an advance directive.
  • The hospital has a mechanism for health care professionals and designated representatives to honor advance directives within the limits of the law and the hospital’s capabilities.

What did the Joint Commission find?

The survey team found several patient records that contained no documentation that a patient or family members had been questioned about advance directives.

Why is this important?

Respecting patient preferences for end-of-life care is dependent upon appropriate documentation being readily available to caregivers where and when they need it.

What are we doing about it?

A careful review of the existing tool for documentation of the advance directive process revealed that the tool itself did not facilitate compliance. It was cumbersome and often left the clinician unclear as to next steps based upon patient response. The form has therefore been revised to more clearly outline action steps for obtaining and documenting advance directives. Since the beginning of March, the form has been piloted on individual units, and those trials have been monitored weekly to ensure ease of use and clarity to staff. 

Where are we now?

Compliance with advance directive documentation has improved from the baseline and at the end of March was slightly above 60 percent hospitalwide, with pilot areas reporting significantly higher results.     By the end of May 2007, hospitalwide compliance had improved to 90%, and areas using the pilot form were reporting 100% compliance.  By September 2007, it measured 94% hospitalwide.

 




Access the redacted Joint Commission report here »


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