September 26, 2003
The journey comes to an end
I t was standing-room
only in the O'Keeffe Auditorium Sept. 19 as MGH employees joined hospital
leadership and surveyors from the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) for an important debriefing, that signaled
the end of the surveyors' visit to the MGH.
The JCAHO survey is one of the most
intense visits from an outside organization a hospital experiences. Every three years the
MGH invites the JCAHO to visit the hospital and review all hospital programs, policies and
procedures. During this year's visit Sept. 15 to 19, JCAHO surveyors also performed the
laboratory survey, which takes place every two years.
"You have a wonderful hospital
here, filled with talented people," said one surveyor at the meeting. "On behalf
of all the surveyors, thank you for making us feel at home."
Following the survey the hospital
received a preliminary report, which was largely a positive response but also
During the next 30 days, the MGH
will continue to review these recommendations and make the appropriate changes needed. The
hospital will then update the JCAHO about the steps that were taken for improvement. The
JCAHO surveyors could possibly come back for a
A final score will then be provided
to the hospital, which will be posted on the MGH JCAHO website. Until then, the MGH will
continue to follow JCAHO requirements, follow up on areas that need to be improved and
report the progress to the JCAHO.
"We understand that there is always room for improvement, especially in an organization as large and complicated as the MGH, but we are very pleased with the survey and the enormous efforts everyone made to prepare for the visit," says Maryanne Spicer, director of MGH Compliance and chair of the JCAHO Steering Committee.
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