Massachusetts General Hospital
Summary of 2012 Joint Commission Survey Findings

If you have any questions or comments about the Joint Commission survey or the findings, please contact Liz Mort, MD, MGH/MGPO senior vice president for Quality and Safety at emort@partners.org ; (617) 724-4638; 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

EC.02.01.01 - The hospital manages safety and security risks.
  • EP 8 - The hospital controls access to and from areas it identifies as security sensitive

What did the Joint Commission find?

MGH routinely conducts environmental risk assessments of hospital areas where vulnerable patient populations receive care. Our two pediatric inpatients units were identified as high-risk areas. Access into these units has been and continues to be controlled by card readers and by our staff who verify the identity of all visitors and confirm the appropriateness of all visits to these units. The survey team found that the units’ exit doors to the stairwells did not have devices to control access from the units into the stairwells.

Why is this important?

It is our duty to protect all patients in our care. The hospital must be appropriately secured to do so. Certain vulnerable patient populations, including newborns and children, require more protection than other patients. While we believe our pediatric patients were appropriately protected prior to our survey, the Joint Commission offered new information that caused us to consider the types of access controls in use.

What are we doing about it?

Additional security devices have been installed on all exit doors of our pediatric units. These devices require authorized access or staff action to exit from the unit on the main and service entrances. As exit into the stairwell cannot be prevented for safety reasons, devices on the stairwell doors sound an alarm if there is any unauthorized entry from the units into the stairwells. Staff members are able to use their identification badges to prevent this alarm from sounding if they chose to use the stairwells and quickly open these doors in times of emergency.

Where are we now?

The devices are installed and working correctly. Appropriate and routine access to the unit has not been affected.


  • IC.02.02.01 - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
    • EP 2-The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.

    What did the Joint Commission find?

    The MGH uses a disinfectant product called Cidex OPA to disinfect certain instruments and equipment after use. A quality check is performed on the Cidex OPA solution to ensure its effectiveness. The manufacturer of Cidex OPA recently clarified the recommended frequency of this quality testing as being before each episode of disinfection regardless of how many times a day the solution is used. One week prior to the Joint Commission survey we revised our policy to include these recommendations and instructed staff to perform the quality check prior to each episode of use during the day instead of daily. The survey team found two hospital locations where the policy had not yet been fully implemented.

    Why is this important?

    Instruments and equipment are designed to be used between many patients must be disinfected between each use. Preventing the spread of infection is a top priority nationwide and is something the MGH takes very seriously. Daily quality checks for effectiveness showed that the Cidex OPA solution was effective, however, it is important to understand and follow a manufacturer’s recommendations when using a product, especially those related to quality control and effectiveness.

    What are we doing about it?

    All hospital locations have been reminded about the policy changes made regarding the frequency of quality control testing of Cidex OPA. Our Infection Control practitioners are continually available for staff consultation and also make routine visits to locations performing this type of disinfection to be sure staff have the correct information needed to perform this important work.

    Where are we now?

    The two locations identified by the survey team put the new policy in place during the survey.


    NPSG.03.04.01 - Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
    • EP 1 - In perioperative and other procedural settings both on and off the sterile field, label medications and solutions that are not immediately administered. This applies even if there is only one medication being used.
    • EP 2 - In perioperative and other procedural settings both on and off the sterile field, labeling occurs when any medication or solution is transferred from the original packaging to another container.

    What did the Joint Commission find?

    MGH staff label hundreds of medication containers every day as the medications are removed from their original containers and placed into syringes and bowls for timely use during an operation or other procedure. In one of our procedural areas the survey team found one unlabeled syringe containing a saline solution. This bowl that contained this syringe was labeled correctly as containing saline. In this instance, both the bowl and the syringe should have been labeled.

    To ensure procedures proceed according to plan there are times when medication containers are pre-labeled. According to the Joint Commission this is an acceptable practice, however, the surveyors felt that our policy was not written as clearly as it could have been to describe the pre-labeling process.

    Why is this important?

    Medications must be handled carefully to keep patients safe. Removing medications from their original container and placing them into another container or delivery system always requires re-labeling of the new container so the medication can always be identified correctly prior to use.

    What are we doing about it?

    In the procedural area where the unlabeled syringe was seen, all staff members have been re-trained regarding the medication labeling process. Leadership of this area will be doing spot checks to be sure all medication containers are labeled.

    We have revised our labeling policy to describe the pre-labeling process in more detail and have distributed this policy to all staff involved in medication labeling.

    Where are we now?

    Hospitalwide education is under way, and routine observational monitoring of labeling practices will follow.


    PC.02.01.03 - The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
    • EP 7 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital provides care, treatment, and services using the most recent patient order.

    What did the Joint Commission find?

    Patients in our intensive care units are often intentionally sedated with medications to assist with their recovery. Our staff members use a variety of tools to measure the depth of sedation. One such tool is called a RASS scale. This scale uses a numerical range to measure a patient’s level of sedation. Our physicians may order medication amounts based on this scale using specific measurements as the target or goal level of sedation. The survey team found that one patient had this type of order in place, but the patient was experiencing deeper sedation than the ordered target. The surveyor noted that the physician’s order did not specify this level of sedation. Our patient record did not describe our thinking about this scenario as clearly as it could have.

    Why is this important?

    Measurement scales establish a common language to help clinicians describe certain patient characteristics and adjust patient care accordingly. This is particularly important when medications are involved.

    What are we doing about it?

    We’ve met with the staff working on the unit where this observation was made and re-educated them regarding the importance of these types of orders matching the patient’s status as closely as possible. We also emphasized with our staff the importance of clear documentation in the patient record. While robust interdisciplinary conversation happens in rounds, the medical record should document key aspects of the teams’ thinking.

    Where are we now?

    We are monitoring our patient record documentation for accuracy.


    PC.03.01.07 - The hospital provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
    • EP 7 - For hospitals that use Joint Commission accreditation for deemed status purposes: A post-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services.

    What did the Joint Commission find?

    The survey team could not locate the post-anesthesia evaluation within one patient record. The patient had been seen by the anesthesiologist shortly after the procedure, however, the documentation was missing from the patient record.

    Why is this important?

    Anesthesia like any other medication requires close monitoring to be sure it is effective and not harmful. All patients receiving anesthesia at MGH are seen by an anesthesiologist after the anesthesia wears off to be sure the patient has fully recovered from the medicine and no side effects are present.

    What are we doing about it?

    All anesthesia staff members have been reminded of the importance of clinical documentation, especially the post-anesthesia evaluation. Patient records will be routinely reviewed over the next several months to be sure our documentation is complete.

    Where are we now?

    We are monitoring our patient record documentation for timely performance of the post-anesthesia evaluation.


    View the Redacted Joint Commission Hospital Report Here


    Requirements for Improvement - Indirect Impact

    EC.02.06.01 - The hospital establishes and maintains a safe, functional environment.

    Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.

    • EP 1 - Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.

    What did the Joint Commission find?

    The surveyors observed that the hinges on the patient bathroom doors on our inpatient psychiatric unit were ‘loop-able’. This means that a patient who has the intention to inflict self-harm could ‘loop’ a material over the bathroom door hinges and attempt to hang himself or herself. The surveyors also observed that we use the Cal-Stat alcohol rub for hand hygiene as we do across the entire hospital. The survey team believed that the number of dispensers on the psychiatric unit and the amount of alcohol gel inside each presented a risk to the psychiatric population as a means of self-injury.

    Why is this important?

    We welcome the observations of the Joint Commission. Because they inspect hospitals all over the country they often bring a valued set of outside eyes to our hospital. We believe the observations made here are of great value and once addressed will promote a safer environment to this sensitive population.

    What are we doing about it?

    We have replaced all the Cal Stat dispensers on the inpatient psychiatric unit with dispensers that supply the same effective cleansing product but in a foam form in lesser amounts. We’ve also inserted a safety screw into each dispenser that prevents it from being opened to access the canister of Cal Stat foam inside.

    We inspected the unit with the goal of identifying less obvious hanging points. As a result of the survey team’s recommendations and our inspection, we have begun to make some renovations to the unit. These renovations include replacing all patient bathroom door hinges with a type of hinge that runs along the inside of door frame and is not loop-able. Our inspection revealed that these patient bathroom door locks and the patient closet doors are also potentially loop-able. We are replacing all bathroom doors, hinges and locks as well as removing all patient closet doors to promote a safer environment.

    Where are we now?

    We are currently replacing the unit’s patient bathroom doors to accommodate the new locks, and we are removing patient closet doors. The unit performs a routine environmental assessment to identify areas of improvement.


    HR.01.02.05 - The hospital verifies staff qualifications.
    • EP 5 - Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented.

    What did the Joint Commission find?

    The MGH provides a volunteer pet therapy program for our patients. We require our volunteers and volunteer pet owners to provide us with routine health screening information to be sure they are in appropriate health to serve our patients. We have a policy that guides our volunteer staff managers and outlines the required health screening information. The Joint Commission reviewed all of our pet therapy dogs’ files and found some files did not contain current health screening information.

    Why is this important?

    Volunteers, including pet therapy dogs, must be in optimal physical and behavioral health to ensure their interactions with our patients are both safe and therapeutic.

    What are we doing about it?

    We have worked with the volunteer pet owners to help them understand our requirements and have successfully updated our records with current health screening information.

    Where are we now?

    All volunteer pet therapy files are up to date. We have revised our review process for these files to improve the identification of soon-to-be-expired health screening information.


    LS.02.01.20 - The hospital maintains the integrity of the means of egress.

    • EP 13 - Exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice.
    • EP 30 - Signs reading 'No Exit' are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may be mistaken for an exit.

    What did the Joint Commission find?

    The life safety specialist from the Joint Commission visited every inpatient location in the hospital and several ambulatory and outpatient locations. In four inpatient care units the surveyor believed that the amount of equipment in the main hallways at the time of the survey was excessive.

    The surveyor also identified a door that needed a “No Exit” sign; this was immediately corrected while the surveyor was on-site.

    Why is this important?

    The use of patient care equipment and temporary storage of this equipment nearby is a constantly changing condition during a typical day here at the hospital. We have in place a continuous quality improvement process that focuses on the current objectives of managing equipment needs while maintaining clear and passable exit corridors. This process has helped to refocus staff awareness, reduce the amount of unnecessary equipment, relocate needed equipment in a timely manner and identify additional storage options. It is an ongoing process and will continue to be so to keep pace with the needs of our patients at any given time.

    It is our responsibility to ensure our signage identifies the safest and most direct path of egress for our patients, staff and visitors in the event of an emergency

    What are we doing about it?

    We have worked with the leadership and staff of the units identified as being out of compliance by the Joint Commission. Focused environmental rounds by our Environmental Health and Safety staff helped identify unnecessary equipment and alternative storage locations.

    Where are we now?

    We will continue with our oversight and support of the improvement process and continue to ensure safe egress from all locations.


    MS.03.01.01 - The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
    • EP 16 - For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff determines the qualifications of the radiology staff who use equipment and administer procedures.
    • EP 17 - For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff approves the nuclear services director's specifications for the qualifications, training, functions, and responsibilities of the nuclear medicine staff.

    What did the Joint Commission find?

    The MGH has a very robust and stringent process for assigning care responsibilities to our staff. This includes the verification of licensure, clinical training ongoing competency assessment and routine medical staff review. The Joint Commission surveyors noted that while we have these assurances in place, our internal documents did not spell out these medical staff responsibilities in a manner they deemed appropriate.

    Why is this important?

    The important medical staff responsibilities described above help to ensure or our mission of providing high-quality and safe patient care.

    What are we doing about it?

    We have updated our internal documents to describe the medical staff responsibilities regarding the qualifications of radiology staff, the director of nuclear medicine and the nuclear medicine staff.

    Where are we now?

    We have updated our internal documents to describe the medical staff responsibilities regarding the qualifications of radiology staff and the nuclear medicine staff.


    MM.03.01.01 - The hospital safely stores medications.
    • EP 3 - The hospital stores all medications and biologicals, including controlled (scheduled) medications, in a secured area to prevent diversion, and locked when necessary, in accordance with law and regulation.

    What did the Joint Commission find?

    The surveyors believed the placement of emergency carts on some of our patient care units did not allow for the carts to be monitored by our staff to prevent tampering or diversion of the medications contained inside.

    Why is this important?

    Emergency carts, sometimes referred to as code carts, are placed in strategic locations on our patient care units to facilitate access during an emergency. These code carts are locked, and the integrity of the lock is checked routinely to ensure tampering or diversion of emergency medicines has not occurred.

    What are we doing about it?

    We have secured the areas where emergency carts are located by restricting access to staff only.

    Where are we now?

    Signage is in place and our emergency carts continue to routinely checked for security and integrity of their locks.


    PC.02.01.21 - The hospital effectively communicates with patients when providing care, treatment, and services.
    • EP 1 - The hospital identifies the patient's oral and written communication needs, including the patient's preferred language for discussing health care.

    What did the Joint Commission find?

    The survey team found that our documentation identifying a patient’s preferred language for receiving health care teaching and related information exchange was unclear.

    Why is this important?

    There are instances when a patient’s primary language is not the language they prefer to receive teaching or other health care related information. Identifying the preferred language helps ensure effective communication between our care teams, patients and patients’ families.

    What are we doing about it?

    We have improved our documentation identifying the patient’s preferred language for receiving health care teaching and related information.

    Where are we now?

    We are routinely reviewing our patient records to be sure the identification of the patient’s preferred language is clearly documented.


    PC.02.02.03 - The hospital makes food and nutrition products available to its patients.
    • EP6 - The hospital prepares food and nutrition products using proper sanitation, temperature, light, moisture, ventilation, and security.

    What did the Joint Commission find?

    A surveyor observed that our Nutrition and Food Service staff members were recording the dishwasher cycle temperatures following breakfast and lunch but were not consistently doing so for the evening meal. Our dishwashers are designed to alarm when cycle temperatures are not within an acceptable range.

    Why is this important?

    Dishwasher cycles have predetermined temperature ranges to ensure effective cleansing and sanitation of dishes and utensils. Although the machines are programmed to maintain these temperatures automatically, periodic monitoring by our staff is routinely performed as a check and balance.

    What are we doing about it?

    Nutrition and Food Service staff will routinely record dishwasher temperature cycles following all three meals each day.

    Where are we now?

    Nutrition and Food Service staff are routinely recording dishwasher temperature cycles following all three meals each day.


    View the Redacted Joint Commission Hospital Report Here


     

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