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Massachusetts General Hospital
2009 Joint Commission Survey Results
A Message from Peter L. Slavin, MD
The MGH’s 2009 Joint Commission Survey Final Report
Massachusetts General Hospital underwent a Joint Commission reaccredidation survey of our hospital and laboratory programs on Aug. 24 to 28, 2009. The nine-member survey team visited our inpatient units, procedural areas, ambulatory practices and laboratories. Our surveyors provided a thorough and comprehensive assessment of our processes of care, documentation, physical plant and many other important facets of our institution.
The preliminary report we received at the end of the survey was quite heartening and reaffirmed for me the relentless pursuit of excellence that I see throughout this hospital every day. The Joint Commission lauded the MGH for the passion and commitment of our staff to delivering high-quality, safe care. The surveyors highlighted many examples of outstanding systems and practices they witnessed during their time at the MGH. They also offered us suggestions about opportunities to enhance what we do. Like every hospital that undergoes a Joint Commission survey, we were given an opportunity to respond to the survey team’s preliminary findings. We worked with Joint Commission staff to provide additional data where needed and clarify our policies and procedures so that the final report was a more accurate reflection of our institution.
As we did during our 2006 hospital and 2007 lab surveys, we are pleased to share the final reports from our 2009 survey.
At the conclusion of a survey, the Joint Commission issues a report listing Requirements for Improvement (RFIs), areas where an organization must respond with corrective action plans. There are two different kinds of RFIs.
- Direct impact RFIs: Direct RFIs are areas of sufficient concern that the Joint Commission believes noncompliance could pose an immediate risk to patient safety or quality of care. To avoid review of accreditation status by the Joint Commission’s central office, a hospital of our type must receive fewer than 13 RFIs on the hospital survey and fewer than 5 RFIs on the laboratory survey. Additionally, a hospital must submit a corrective action plan addressing each direct impact RFI within 45 days.
- Indirect impact RFIs: Indirect impact RFIs are considered to pose a less immediate risk to patient safety and quality of care. These RFIs do not have a bearing on an accreditation decision, but are still relevant and important to providing high-quality, safe patient care. A hospital must respond to these findings with a corrective action plan within 60 days.
On our hospital survey, MGH received 2 direct impact RFIs, and 6 indirect impact RFIs. On our laboratory survey, we received 3 direct impact RFIs, and 8 indirect impact RFIs. During the exit conference, our survey team noted that MGH’s performance was “outstanding” for an institution of our size and complexity, and among the best survey results they had seen this year.
Despite this welcome endorsement, we will not rest easy with even this low number of RFIs. Our goal remains not only zero RFIs on a Joint Commission survey, but also Excellence Every Day—providing the highest quality, safest care that meets or exceeds all standards set by external groups and our own internal standards. We are working diligently to respond to the findings of this report, and to improve upon our policies, processes and systems of care to provide the very best for our patients and families. They deserve nothing less.
I invite you to click the link below to find out more about our survey performance, how we are responding, and to review our survey reports. My thanks to all of you for making this survey experience a successful one, and I look forward to working with you to advance our care to an even higher level.
Peter L. Slavin, MD
President
Massachusetts General Hospital