December 15, 2006

JCAHO surveyors visit the MGH for a full hospital survey

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) made its unannounced full hospital survey of the MGH during the week of Dec. 11. JCAHO is an independent, not-for-profit organization that evaluates and accredits health care organizations throughout the United States to help assure the quality of care provided to the public. The survey lasted five days, during which JCAHO surveyors visited clinical areas — including inpatient and outpatient units — and interviewed employees about patient safety, the hospital's mission, fire and disaster planning, quality improvement and patient rights. Surveyors paid close attention to the environment of care, interviewed patients and reviewed clinical records, policies and procedures as they "traced" the care of selected patients using the newly adopted tracer methodology.

The JCAHO operations committee, led by Maryanne Spicer, director of Corporate Compliance, regularly has met for the past two years to discuss issues related to the survey and to prepare MGHers for the unannounced visit. Preparation and education has included mock surveys, audio conferences, information tables and the FYI campaign, which consisted of information papers, posters and articles in MGH Hotline.

"Employees and staff involved with this survey worked incredibly hard to make sure the surveyors received the information that they needed," says Spicer. "I am continually impressed by the dedication of all employees throughout this organization who are committed to providing the best possible care to our patients. While the survey can be challenging, it allows us to showcase the hard work of our employees, and it gives them an opportunity to really shine."

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