April 2, 2010
Massachusetts General Hospital underwent an unannounced survey from the Centers for Medicare and Medicaid Services (CMS) from Feb. 2 to Feb, 16, 2010. CMS undertakes such unannounced surveys for two major reasons: 1.) to validate the findings of The Joint Commission, the organization that accredits health care facilities, and 2.) to assess the hospital’s compliance with the CMS’s Conditions of Participation. The interpretive guidelines for these regulations have been modified over time, though the last major revision to the conditions was completed in 1986. They are designed to assess compliance with a range of standards that support the provision of high quality, safe care, such as governance, patient rights, infection control, quality assessment, and medical records. Full compliance with these conditions is needed for a hospital to receive payment for services from Medicare and Medicaid. Each year, approximately 5 percent of hospitals in the nation that undergo a Joint Commission survey also undergo a CMS validation survey. The hospitals surveyed are chosen randomly; in fact, the MGH had its last CMS validation inspection 35 years ago.
In contrast to a Joint Commission survey, which focuses on quality and safety by following patients through the health care process, the CMS review process relies more heavily on documentation, policies and facility inspection. The 16-member CMS team’s evaluation was rigorous, encompassing medical record reviews, staff and patient interviews, examination of policies and procedures, and inspections of the environment of care. The survey team visited nearly all of our inpatient units and most of our hospital-licensed outpatient practices.
Shortly after the survey, the MGH was issued a report detailing the deficiencies the survey team identified, asking us to provide plans of correction for each area cited. Earlier today, CMS informed us that they had officially accepted our plans of correction. As we did during our previous Joint Commission surveys, we are pleased to share the final report and corrective action plans from our CMS validation.
I encourage you to click the link below to read the summary of CMS’s survey findings, how we are responding, and to review the survey report itself. We are working diligently to implement the plans of correction outlined in the report, and some of the key areas we are addressing include physiologic monitoring practices, the protection of sensitive patient information, and the maintenance of our physical environment.
The MGH remains committed to Excellence Every Day—providing the highest quality, safest care that meets or exceeds all standards set by external groups and our own internal standards. This recent survey is an opportunity to reexamine our policies, processes and systems of care to ensure that we are providing the very best for our patients and families. They expect and deserve nothing less.
I would like to extend my heartfelt thanks to the many staff and managers who worked collaboratively with the CMS survey team during the survey, and prepared plans of correction after the survey. I look forward to working with you to advance our care to an even higher level.