Massachusetts General Hospital
Summary of 2017 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 ; (617) 724-4638; or John Belknap, MGH Chief Compliance Officer at, (617) 726-5109.

The Joint Commission (TJC) conducted its triennial reaccreditation survey of the Massachusetts General Hospital on November 13 through November 17, 2017. A team of eight surveyors from TJC visited the MGH main campus and satellites for a five-day unannounced survey. The team consisted of two physicians, four nurses, one life safety engineer, and one addiction specialist.

As we anticipated based on our internal risk assessment and nationwide trends, the surveyors focused on soiled instrument pre-cleaning and transport, sterile processing and high-level disinfection, medical equipment management, behavioral health patient safety, fire and life safety, the environment of care, and the accuracy of provider orders. Surveyors traced these focus areas throughout the main campus and at several of our satellite locations. The surveyors noted improvements in many of these areas that were well underway, however not yet fully completed or not broadly implemented.

This survey was the MGH’s first full accreditation review using the new SAFER™ scoring methodology (example below). This method is aimed at assisting organizations in prioritizing their areas of non-compliance by categorizing each finding using two parameters: likelihood of patient/visitor/staff harm and scope. Likelihood of patient harm is assessed as either low, moderate, high, or immediate threat to life. Scope is determined to be either limited, pattern, or widespread. The survey team identified 33 areas of non-compliance. Twenty of these findings were single observations categorized as being low likelihood of harm and of limited scope, with only one finding assessed as high likelihood of harm with a pattern of scope.


The MGH opts to undergo what is referred to as a deemed-status survey. What this means is that MGH elects to have TJC survey our organization on behalf and instead of The Centers for Medicare and Medicaid Services (CMS). A large majority of The Joint Commission’s standards are mapped or cross-walked to corresponding requirements within the CMS Hospital Conditions of Participation. Due to the nature of the surveyors’ findings related to fire and life safety, behavioral health patient safety, sterile processing, and the environment of care, the MGH received three CMS condition-level citations. The conditions cited included the physical environment, infection control, and surgical services.

Observations that triggered the physical environment condition-level finding included incorrect soiled instrument transport, ligature risks in the behavioral health unit, incomplete medical equipment maintenance, hallway storage, and other miscellaneous observations related to fire and life safety. Surveyor findings that resulted in a condition-level finding under infection control included soiled and worn furnishings, as well as an expired product used for low-level disinfection. The surgical services condition was cited due to deficient high-level disinfection practices, inappropriate soiled instrument pre-cleaning and transport, and incorrect sterile instrument storage.

Condition level findings require TJC to make a Medicare Deficiency follow-up survey within 45 days of the initial survey. On December 21, 2017, two surveyors from TJC visited the MGH and found that we had successfully corrected all but one CMS related deficiency: the replacement of all our behavioral health beds. The soonest the beds could be delivered was January 10, 2018. On January 16, 2018, one surveyor TJC returned to the MGH and determined we had achieved compliance with all CMS related deficiencies.

The remaining observations of non-compliance required submission of plans of correction by January 29, 2018. TJC accepted our plans of correction on February 2, 2018 and determined that all areas were fully compliant.

View the Redacted Joint Commission Hospital Report Here


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