Massachusetts General Hospital
Summary of 2009 Joint Commission Survey Findings

If you have any questions or comments about the Joint Commission survey or the findings, please contact Gregg Meyer, MD, MGH/MGPO senior vice president for Quality and Safety at gmeyer@partners.org, (617) 724-9194; or John Belknap, MGH director of Corporate Compliance at jbelknap@partners.org, (617) 726-5109.

Note

In the summary below, we have included the specific Joint Commission standards on which we received citations. The Joint Commission’s numbering convention includes acronyms for chapter names, as well as numbers outlining chapter sections. Each standard also includes Elements of Performance (EP) that detail the Joint Commission’s specific performance expectations for each standard. EPs are scored during survey and determine our compliance with each standard, and so they are listed below.

Hospital Program Survey

Requirements for Improvement – Direct Impact

  1. MM.04.01.01 – Medication orders are clear and accurate
    • EP 13 – The hospital implements its policies for medication orders

    What did the Joint Commission find?

    MGH policy requires that any medications brought from home by patients be verified by a hospital pharmacist and labeled as such.  The Joint Commission survey team found three instances where medications brought in by patients did not have verification labels on them from the MGH pharmacy.

    MGH policy also requires that there be distribution logs for any sample medications kept in clinical practice areas. The Joint Commission survey team found a practice location where a log was not present.

    Why is this important?

    Pharmaceuticals are used in virtually every phase of patient care, and careful, systematic monitoring of utilization is essential to patient safety. Home medications brought into a hospital or medical office environment must be verified because these medications may interact with any medications substituted or added to a patient’s regimen. For similar reasons, keeping an accurate record of sample medications dispensed is also crucial.

    What are we doing about it?

    We are undertaking a systematic review of our home medication labeling practices, and will be implementing changes to more easily facilitate these processes. This may include some modifications to the electronic medical record (EMR) as well as policy and procedure changes. For sample medications, we are continuing to audit compliance with our policies.

    Where are we now?

    We will be conducting audits of our home medication management processes to ensure compliance with policy changes. Sample medication practices were monitored prior to survey, and those audits will continue and intensify.

  2. NPSG.03.04.01 – Label all medications, containers (for example syringes, medicine cups, basins), or other solutions on and off the sterile field
    • EP 1 – Medications and solutions both on and off the sterile field are labeled even if there is only one medication being used
    • EP 2 – Labeling occurs when any medication or solution is transferred from the original packaging to another container
    • EP 3 – Medication or solution labels include the medication name, strength, amount (if not apparent from the container), expiration date when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours.

    What did the Joint Commission find?

    During survey, the Joint Commission found instances where medications being used in patient care did not have labels on them. They also found two instances where medications transferred from an original, labeled container did not have labels on the other container. They also found two instances where the label was missing information about medication strength and amount.

    Why is this important?

    Medication administration errors can result from giving an incorrect medication, an expired medication, or an incorrect strength or volume a medication. Clearly and properly labeling a medication with relevant information greatly reduces these risks, so much so that the Joint Commission has rightly deemed this requirement a National Patient Safety Goal. Medications are used in nearly every phase of patient care, which can make complying with this requirement a challenge.

    What are we doing about it?

    We are reeducating our staff about the importance of labeling medications with the correct information, and when transferring medications into another container. Many areas in our hospital have excellent medication labeling processes, and we will work to ensure those practices are transferred to any areas needing attention

    Where are we now?

    We are conducting audits of the medication labeling processes in the areas cited by the surveyors to help us understand where the breakdowns in process are, and refine our education efforts.

    Requirements for Improvement - Indirect Impact

    The hospital program received six (6) indirect impact RFIs that did not pose an immediate threat to patient safety or quality of care, but that are important for us to address. Of the 6 RFIs, three were environment of care standards, two were medication safety related, and one was a Life Safety Code issue. We invite you to review the final report for additional details on each, and follow up with the report contacts listed above if you have any questions. All indirect impact RFIs will have corrective action plans in place within 60 days.

    View the Redacted Joint Commission Hospital Report Here

Laboratory Program Survey

The Massachusetts General Hospital laboratory program covers 30 laboratory testing sites across the main hospital campus and satellite locations. Multiple observations may reflect different laboratory locations and CLIA certificates.

Requirements for Improvement – Direct Impact

  1. EC.3.10 – The laboratory manages its hazardous materials and waste risks
    • EP 9 – The laboratory identifies and implements emergency procedures that include the specific precautions, procedures, and protective equipment used during hazardous materials and waste spills or exposures
  2. What did the Joint Commission find?

    During survey, the Joint Commission found eyewashes in a laboratory and near a nursing station that were attached to hot water and were lacking a regulator that prevented the water temperature from exceeding 100 degrees Fahrenheit.

    Why is this important?

    Eye washes are present in laboratories and patient care areas so that if caregivers, laboratory technicians or patients receive hazardous materials in their eyes they are able to wash them out quickly and reduce the risk of eye injury. The eyewashes themselves must also function safely, and washing eyes with water of too high a temperature can cause damage.

    What are we doing about it?

    As noted in the report, the two eye washes the Joint Commission cited during survey were quickly repaired so that they included temperature regulators. We are undertaking a more systematic review of our eye wash stations to ensure all of them are in compliance.

    Where are we now?

    We will continue to carefully survey eyewash stations across the institution to ensure they function safely and correctly.

  3. QC.1.20 – Proficiency testing services used for specialty and subspecialty equal or exceed applicable laws and regulations with respect to variety and frequency of testing and satisfactory performance criteria.
    • EP 7 – For each subspecialty, analyte, or test, the laboratory’s proficiency test performance is satisfactory.

    What did the Joint Commission find?

    During survey, the Joint Commission found that proficiency testing results for several types of laboratory tests fell into unsatisfactory ranges, per regulation.

    Why is this important?

    Proficiency testing is a quality assurance process required of Joint Commission-accredited labs. Our lab receives samples from an outside agency for which test results are not known, performs tests on those samples, and returns the results to the outside agency. These results are evaluated and compared to other laboratories doing the same test. This is an excellent process for obtaining an unbiased, external validation of how our lab testing processes are working, and allows us to quickly identify opportunities for improvement.

    What are we doing about it?

    Because of the scoring of the standard, we received an RFI because there were more than two instances of out-of-range proficiency test results. As noted in the report, there were already documented corrective actions in response to the tests that did not meet the performance thresholds outlined in the standards, and we continue to implement those actions.

    Where are we now?

    We continue to fully comply with the proficiency testing requirements, and will document corrective actions on an as needed basis.

  4. IC.4.10 – Once the laboratory has prioritized its goals, strategies must be implemented to achieve those goals
    • EP 3 – Interventions are implemented which include the following
      • Methods to reduce the risks associated with procedures and laboratory equipment including the following: appropriate storage, cleaning, disinfection, sterilization, and/or disposal of supplies and equipment.
      • Reuse of equipment designated by the manufacturer as disposable in a manner that is consistent with regulatory and professional standards
      • The appropriate use of personal protective equipment

What did the Joint Commission find?

This citation relates to infection control specifically in a laboratory environment. During survey, the Joint Commission team observed that a medical assistant completed a strep screen without wearing gloves.

Why is this important?

It is crucial to take steps to reduce the spread of infections in all settings – inpatient units, procedural areas, ambulatory practices, and laboratories. In this case, failure to wear protective equipment (gloves) while conducting a screening test can contaminate the sample being tested, as well as spread potentially infectious agents from the sample to the healthcare worker.

What are we doing about it?

It is essential that our employees understand proper infection control practices, including how to appropriately handle laboratory test specimens. We are reeducating staff about the importance of proper infection control procedures during tests like this one.

Where are we now?

We will undertake periodic audits of staff performance with this standard to ensure that our educational efforts are working, and will tailor those efforts accordingly.

Requirements for Improvement - Indirect Impact

The laboratory program received eight (8) indirect impact RFIs that did not pose an immediate threat to patient safety or quality of care, but that are important for us to address. Of these 8, here were some of the findings:

  • There was a clerical issue with our laboratory certificate in which a certain test being performed was missing on the certificate.
  • Temperature monitoring logs for reagents used in blood-gas testing in one of our laboratories were missing
  • There were four RFIs related to the Joint Commission’s various lab quality control regulations. For example, laboratory documentation showed that certain agents used in testing were stored at a temperature a few degrees out of the manufacturer’s recommended range. Other quality control RFIs related to how often we performed quality control testing on certain lab procedures.
  • The remaining two RFIs related to “waived testing.” Waived tests are tests that are deemed by regulation as being so simple and accurate that the likelihood of erroneous results is negligible, or pose no risk of harm to a patient if performed incorrectly. The Joint Commission identified that one strep screen was not labeled in accordance with MGH policy, and also found that a policy for the quality control of pH paper used during eye exams was not available.

All indirect RFIs will be addressed with plans of correction within the 60 day time frame required by the Joint Commission. We invite you to review the report for additional information.

View the Redacted Joint Commission Laboratory Survey Report Here

 

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