January 28, 2000

The new year starts a countdown to the MGH's next survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The full hospital survey — a comprehensive review of hospital programs, policies and procedures — is expected to take place sometime in September.

The JCAHO is an independent, not-for-profit organization that evaluates and accredits more than 19,500 health care organizations in the United States, including hospitals, health care networks, managed care organizations and other entities that provide home care, long-term care and laboratory and ambulatory care services.

The goal of the JCAHO is to help improve the quality of care provided by accrediting health care organizations that qualify after completion of a thorough inspection. During a survey, hospitals and other organizations are measured against standards in important functions such as leadership, patient care, performance improvement and maintaining a safe environment.

Although the JCAHO accreditation process is voluntary, most hospitals seek out survey approval because Medicare, Medicaid and many state agencies and third-party payors require JCAHO accreditation for participation.

JCAHO performs full hospital surveys once every three years, with lab surveys and unannounced surveys conducted in between. Full hospital surveys typically last three to five days, during which several surveyors visit clinical areas, such as physician practices and patient care units, and procedural areas, such as operating rooms and cardiac catheterization labs. Surveyors also may interview employees and staff about such topics as the hospital's mission, fire and disaster planning, quality improvement initiatives and patient rights.

In the last JCAHO visit in 1997, the MGH received a score of 91 percent — the best score the hospital has ever received on the survey. The score translated into full accreditation status with a few areas recommended for improvement.

Employees from throughout the hospital have been preparing for this year's survey since the 1997 JCAHO visit. A steering committee, chaired by Maryanne Spicer, director of Corporate Compliance, has been meeting regularly over the last year to discuss issues related to the survey. In addition, several mock surveys have been conducted during the past year to help staff prepare for the actual JCAHO visit and find any problem areas that need to be addressed before the fall survey.

Results of the mock surveys included recommendations for such improvements as refining patient and family education on details of care, improving patient documentation, increasing use of employee performance evaluations hospitalwide and incorporating competency assessments in evaluations.

"Ensuring high quality of care and compliance with JCAHO standards is a team effort, requiring every employee and staff member at the hospital to participate," says Spicer. "It takes all of us working together to have a successful visit from the Joint Commission. And it is a good opportunity both to demonstrate our commitment to our patients and to get an outside perspective on how we provide care."

The JCAHO steering committee will continue 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 poster in the FYI series (above) summarizes what steps should be taken in case of a fire and recently was distributed throughout the hospital.

An all-day JCAHO training session will be held in September before the survey to help employees and staff prepare for the visit. MGHers also can view a listing of JCAHO standards through the Comprehensive Accreditation Manual for Hospitals, which is found on-line from any Partners workstation by accessing Partners Applications, Clinical References, CAMH 1999.

For more information about how to prepare for the JCAHO survey, MGHers can contact Spicer at 6-5109 or any of the following JCAHO steering committee members: Dom Misiano, Clinical Pathology; Cy Hopkins, MD, Infectious Disease Unit; Elyce Kearns, MD, Psychiatry; Kathleen Erwin, Ambulatory Care Practice Support; Jan Swanson and Rebecca Silver, Human Resources; Debbie Adair, Health Information Management; George MacNeil, Buildings and Grounds; and Joan Fitzmaurice, RN, PhD, Patient Care Services.