Massachusetts General Hospital
Summary of 2015 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 Chief Compliance Officer 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.

Joint Commission 2015 Hospital Survey Summary

Direct Impact Findings

Record of Care (02.01.03) - The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

  • Element of Performance 7 - When a full operative or other high-risk procedure report cannot be entered immediately into the patient’s medical record after the operation or procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care. This progress note includes the name(s) of the primary surgeon(s) and his or her assistant(s), procedure performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis.

What did the Joint Commission find?

MGH performs thousands of operative procedures each year. The survey team found five brief operative notes either missing or incomplete.

Why is this important?

The purpose of the brief operative note is to provide the clinicians with information regarding the course of the surgical procedure prior to the full operative note being dictated and transcribed.

What are we doing about it?

All surgical staff have been reminded of the importance of writing a complete brief operative note for every invasive surgical or procedural case.

Where are we now?

MGH will monitor the presence and completeness of brief operative notes for at least four consecutive months or until a high level of compliance is achieved.


Environment of Care (02.05.09) - The hospital inspects, tests, and maintains medical gas and vacuum systems.

  • Element of Performance 1 - In time frames defined by the hospital, the hospital inspects, tests, and maintains critical components of piped medical gas systems, including master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. These activities are documented.
  • Element of Performance 3 - The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control.

What did the Joint Commission find?

MGH routinely tests medical gas systems. The Joint Commission believed our testing and our documentation of this testing needed additional detail to ensure that our medical gas systems were functioning as designed.

MGH procedural areas contain many types of rolling equipment including patient stretchers. At two procedural locations, stretchers were observed temporarily parked in front of medical gas control valves.

Why is this important?

It is our duty to maintain and ensure the safe and effective operation of all hospital utility systems. Many hospitalized patients depend on medical gases such as oxygen as an important part of their plan of care.

In the event of a fire or other disaster, medical gas controls must be easily accessible by staff if they are directed to turn off or adjust these controls.

What are we doing about it?

We have consulted with our medical gas testing vendor to review and revise our testing procedures to ensure they are comprehensive and effective in identifying any abnormalities. We have improved the documentation of our medical gas testing by adding the information necessary to establish safe and comprehensive testing.

The stretchers have been re-located so that access to the medical gas valves remains unobstructed.

Where are we now?

Our medical gas systems are being routinely inspected and tested according to our revised procedures and improved process for capturing testing results.

In addition to the daily vigilance of staff, MGH conducts routine, periodic environmental surveillance rounds in all hospital locations. Both procedural locations will be visited to ensure the environment and safe and prepared in the event of a fire or other disaster.


Infection Control (02.02.01) - The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.

  • Element of Performance 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.
  • Element of Performance 4 - The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies.

What did the Joint Commission find?

MGH has very specific procedures to ensure the effective cleaning and disinfection of medical equipment. The surveyors noted an inconsistency in how we measure and dilute a cleaning solution in two separate locations. They also observed a piece of used equipment incompletely covered and marked as used while on its way to be cleaned. Certain equipment used in surgical procedures is packaged twice after sterilization; the surveyors believed we could improve this technique to ensure the innermost sterility marker was visible to all staff. The survey team also noted that testing procedures for one of our sterilizers had not been modified following a visit by the manufacturer during which settings for the device had been changed.

MGH uses thousands of types of supplies to care for our patients. The Joint Commission surveyor found a package of expired suture material, two expired blood testing tubes and an expired container of test strips used during disinfection procedures.

Why is this important?

Instruments and equipment are designed to be used between many patients and must be disinfected between each use. Preventing the spread of infection is a top priority nationwide and is something the MGH takes very seriously. Cleaning and disinfecting procedures, including the transport of used equipment must be consistent across all hospital locations and performed according to the particular manufacturers’ recommendations.

Expired supplies may be less than effective for the intended purpose and may contribute to an undesired result.

What are we doing about it?

We have modified our procedures for transporting used equipment, measuring and diluting cleaning solutions as well as packaging sterilized equipment so they are consistent across all locations and follow manufacturers’ recommendations. We have modified the testing procedures for our sterilizer so it is also consistent with manufacturers’ recommendations.

The expired supplies were immediately removed from stock and an examination of the remaining supplies conducted.

Where are we now?

MGH conducts routine interdisciplinary clinical tracer evaluations and environmental surveillance rounds to assess the effectiveness of our safety strategies, quality of care and the corrective action methods we’ve put in place. Equipment cleaning, transport, quality and inventory control methods are observed and evaluated during these rounds.


View the Redacted Joint Commission Hospital Report Here


Indirect Impact Findings

Environment of Care (02.06.01) - The hospital establishes and maintains a safe, functional environment.

  • Element of Performance 1 - Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.
  • Element of Performance 13 - The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided.

What did the Joint Commission find?

The surveyors observed a missing ceiling tile, a stained ceiling tile; two bathroom call-light cords that were looped around the bathrooms’ grab bars and an unsecured oxygen cylinder laying on a stretcher belonging to an outside EMS service. The surveyors also noted that we did not correctly measure and record the humidity of two sterile storage locations.

Why is this important?

Intact ceiling tiles play an important role in smoke and fire containment as well as sprinkler function. Bathroom call-light cords need to be in reach of a patient who may have fallen to the floor. Oxygen cylinders must be secured appropriately to reduce the risk of injury should a cylinder be inadvertently knocked and its contents released. Monitoring the humidity of sterile storage locations helps to ensure the sterility of wrapped supplies is not compromised.

What are we doing about it?

The missing and defective ceiling tiles were immediately replaced and the bathroom call-light cords unwrapped from the grab bars. The oxygen cylinder was returned to the EMS service. We installed humidity monitors in the necessary locations and routine monitoring now occurs.

Where are we now?

We have a focused monitoring process in place monitoring the presence and integrity of ceiling tiles, bathroom call-light accessibility and the security of oxygen cylinders weekly for four consecutive months. Additionally, we have enhanced our routine environment of care surveillance rounds to include an assessment of these issues on an ongoing basis.


Life Safety (02.01.10) - Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

  • Element of Performance 5 - Doors required to be fire rated have functioning hardware, including positive latching devices and self-closing or automatic-closing devices. Gaps between meeting edges of door pairs are no more than 1/8 inch wide, and undercuts are no larger than 3/4 inch.
  • Element of Performance 9 - The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material.

What did the Joint Commission find?

A surveyor observed two fire rated doors with deficiencies. One door did not self-close and latch correctly and the other, a set of double doors was noted to have a gap at the meeting edges of the doors measuring greater than 1/8”. The surveyor also found one junction box cover missing inside a telephone/data closet as well as three locations where mixed fire-stopping caulking materials were used instead of one uniform type of caulking to seal a smoke or fire barrier penetration.

Why is this important?

Meeting life safety requirements is essential so that patient, staff and visitors are protected in the event of a fire or smoke incident. These building features aim to contain smoke and/or fire so that patients may be protected in place or evacuated along a safe route if need be.

What are we doing about it?

The deficient doors and missing junction box cover were repaired during survey. The deficient fire-stop caulking has been replaced with a uniform type of fire-stop material.

Where are we now?

We have enhanced our routine environment of care surveillance rounds to include an assessment of these issues on an ongoing basis.


Life Safety (02.01.20) - The hospital maintains the integrity of the means of egress.

  • Element of Performance 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.

What did the Joint Commission find?

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

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.

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 and Patient Care Services Support staff helped identify unnecessary equipment and alternative storage locations.

Where are we now?

We will continue with our oversight and support of our ongoing surveillance and improvement processes and continue to ensure safe egress from all locations.


Life Safety (02.01.30) - The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

  • Element of Performance 2 - All hazardous areas are protected by walls and doors in accordance with NFPA 101-2000, in many cases this means functioning sprinkler systems.
  • Element of Performance 9 - In existing buildings, all corridor doors are constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and do not have ventilating louvers or transfer grills.
  • Element of Performance 11 - Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so that they swing. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 1 inch. Roller latches are not acceptable.
  • Element of Performance 23 - Doors in smoke barriers are self-closing or automatic-closing, constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and fitted to resist the passage of smoke. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 3/4 inch. Doors do not have nonrated protective plates more than 48 inches above the bottom of the door.

What did the Joint Commission find?

The survey team observed two missing escutcheon plates in an ambulatory location as well as three corridor doors on the main campus with fire damper louvers instead of smoke damper louvers. The life safety surveyor noted that in five suited locations – ICUs and procedural areas, the exit doors did not latch correctly. The same surveyor found two sets of double smoke doors where the leading edges had a gap that exceeded 1/8 inch.

Why is this important?

Meeting life safety requirements is essential so that patients, staff and visitors are protected in the event of a fire or smoke incident. These building features aim to contain smoke and/or fire so that patients may be protected in place or evacuated along a safe route if need be. Escutcheon plates seat a sprinkler head to the ceiling and act as both a heat detector as well as a deflector, aiming sprinkler water downwards.

What are we doing about it?

The missing escutcheon plates have been replaced, the doors with fire dampers have been replaced with smoke dampers, the suite doors latching hardware has been either repaired or replaced and the two sets of double smoke doors have been repaired.

Where are we now?

We have enhanced our routine environment of care surveillance rounds to include an assessment of these issues on an ongoing basis.


Transplant Safety (03.02.01) - The hospital traces all tissues bi-directionally.

  • Element of Performance 2 - The hospital identifies, in writing, the materials and related instructions used to prepare or process tissues.

What did the Joint Commission find?

The surveyor noted that we did not retain the manufacturers’ written instructions for preparation and use of tissue used in implantation.

Why is this important?

Tissue preparation prior to implantation is a critical step contributing to a successful surgical outcome. Retaining the instructions for preparation and use is important in the event of a product recall, product failure or unfavorable surgical outcome.

What are we doing about it?

We have contacted all tissue vendors and obtained their manufacturers’ written instructions for preparation and use. These instructions have been posted in an electronic format in a shared file location accessible to all relevant peri-operative staff.

Where are we now?

All surgical cases involving tissue implantation will be reviewed weekly for four consecutive months to assess for the presence of the written instructions for preparation and use. Periodic monitoring will commence thereafter.


View the Redacted Joint Commission Hospital Report Here


 

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