July 24, 2003

They're back: Countdown to JCAHO

Time may fly when you're having fun, but MGHers know that time also flies when you're busy planning. It's been three years since the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveyed the MGH, and the hospital is once again preparing for the intensive review. The survey, which includes a comprehensive review of hospital programs, policies and procedures, as well as lab surveys, will take place Sept. 15 through 19.

JCAHO is a nonprofit organization that evaluates and accredits more than 19,000 health care organizations in the United States. The goal of JCAHO is to help improve the quality of medical care by accrediting health care organizations that are deemed to meet specific standards after completion of a thorough inspection.

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 and procedural areas. Surveyors also may interview staff about a variety of hospital topics.

How is the MGH preparing for the survey? For the past year, the JCAHO steering task force, led by Maryanne Spicer, director of MGH Corporate Compliance, has been busy preparing the hospital and its employees for the upcoming survey. The task force is a multidisciplinary committee that works to inform employees about changes in JCAHO's standards and new areas of emphasis. According to Spicer, the hospital and its employees should be survey-ready every day. During this critical preparation period, the role of the task force is to help "raise the bar" to meet the initiatives the JCAHO has set.

Several mock surveys designed to help staff members in assessing their readiness for the JCAHO survey have been conducted recently in various areas and departments. "We're stepping up our efforts in preparing for the survey," says Spicer. "We now are in the final stages of preparations, and I am highly confident that our dedication and commitment to our patients will once again shine when the survey is complete."

In the weeks leading up to the survey, the task force also will continue with the FYI campaign, which includes posters and papers that convey information about the survey and what every hospital employee needs to know. The FYI papers have focused on topics such as infection control, performance evaluations and patient assessments. The posters have focused on topics such as emergency codes, patient safety and confidentiality.

Another important message the task force wants to convey is that the survey is a hospitalwide effort that includes participation by all employees. "It is important that all hospital staff work together to represent the hospital well during the survey and help us ensure a successful visit with the surveyors," says Spicer. "It truly is a team effort. All employees are encouraged to speak to their managers to understand how they fit into the survey process."

For more information about how to prepare for the JCAHO survey, contact Spicer at (617) 726-5109.