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Health Law

: HealthBlawg

MGH prepares for its next Joint Commission survey

By David Harlow

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The fact that a hospital has a Joint Commission survey due within the next year or so is not ordinarily newsworthy. However, the Boston Globe spilled some ink today on the Massachusetts General Hospital's upcoming survey and the General's preparations -- including a mock survey, which is a standard preparation tool, particularly for facilities that have been working on improving their performance. Last survey cycle, MGH was dinged for issues including recordkeeping and lax handwashing practices (look down a few grafs), and the mock survey was not quite perfect. Then again, who's perfect?

The Globe's Jeffrey Krasner reported:

In a recent e-mail to staff, Dr. Peter Slavin, Mass. General's president, said the survey showed some areas still need improvement and must be addressed "immediately."

Slavin said the hospital has to make sure staff members better follow "universal protocols," or sets of instructions for individual procedures; ensure that patients have physicals 24 hours before surgery; improve the documentation of anesthesia and sedation procedures; and more closely monitor patients who are in pain.

The hospital has also begun an internal communications program, called Excellence Every Day.

The General seems to be emphasizing the continuous quality improvement approach to hospital operations, which is laudable. It also brings to mind the focus of the Joint Commission's new rival, DNV.

The article continued:

It found that while there is perfect compliance with universal protocols in operating rooms, throughout the entire hospital the step was only followed 84 percent of the time . . . . In conducting a universal protocol, doctors and nurses review an upcoming procedure, make sure they have all the necessary supplies, and come to a "full stop," in which everyone stops what they're doing and makes eye contact before proceeding.

Survey or no, this is clearly an important effort, and one the General can devote resources to as it strives to maintain its level of clinical excellence.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Full post as published by HealthBlawg on November 18, 2008 (boomark / email).