March 31, 2000

The MGH recently received an application from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which means a team of JCAHO surveyors will be visiting the hospital sometime this fall. The JCAHO visit will be a comprehensive review of hospital programs, policies and procedures.

"We now are making the final preparations for the survey," says Maryanne Spicer,

director of Corporate Compliance and chair of the JCAHO steering committee. "Throughout the hospital, individuals and departments are stepping up their survey training and planning, with the support of the hospitalwide JCAHO steering committee."

Most hospital departments have been preparing for the survey since the last one took place three years ago. For example, the Human Resources (HR) Department offers several support initiatives to help managers meet JCAHO standards for human resources management.

HR initiatives include monthly reports to managers listing fiscal year 2000 employee performance evaluations that are due and those completed to date; revised JCAHO-compliant job description and performance evaluation templates; and newly created age-specific and position-specific competency assessment forms, all of which are located on the MGH Intranet at http://is.partners.org/hr/forms/index.html.

HR staff members will work closely with MGH managers over the coming months by offering workshops and meeting with individual departments to help managers meet JCAHO human resources standards and to provide specific information about competency assessment, an anticipated "hot button" for this year's survey.

The Outpatient Practice Support Unit also is getting into high gear to prepare for the survey. Outpatient staff have borrowed the game-show idea from ABC-TV's "Who Wants to be a Millionaire?" to create a fun and innovative way to prepare the outpatient practices for the survey — "Who Wants to be a JCAHO-Standardaire?" The practices are organizing cross-functional teams to answer five JCAHO-related questions by e-mail. Team members can refer to their "lifelines," in this case, the JCAHO standards manual or the online version of the Comprehensive Accreditation Manual for Hospitals.

The JCAHO steering committee continues to use the FYI campaign, which includes posters, e-mails and newsletter articles, to convey important information about the JCAHO survey preparations to MGHers. The next FYI poster about the hospital's mission is being distributed throughout the hospital this week.

A series of fliers called the FYI Papers is being added to the campaign to help inform employees about specific topics such as quality improvement activities, patient confidentiality and patient care assessment. The first of the FYI Papers — about ethical standards and resources at the MGH — is being distributed next week to patient units and departments.

The JCAHO steering committee also can provide a self-assessment checklist to help department heads evaluate their department's readiness for the survey.

For more information about the JCAHO survey, call Spicer at 6-5109.