Massachusetts General Hospital
2012 Joint Commission Survey Results

A MESSAGE FROM PETER L. SLAVIN, MD, MGH PRESIDENT, TO THE MGH COMMUNITY

Massachusetts General Hospital underwent a Joint Commission reaccreditation survey from July 23 to 27, 2012. The six-member survey team visited our inpatient units, procedural areas, ambulatory practices and laboratories. The surveyors provided a thorough and comprehensive assessment of our processes of care, documentation, physical plant and many other important facets of our institution.

The weeklong visit reaffirmed how truly special our organization is – a point the survey team made over and over – and it also taught us a great deal. At the conclusion of a survey, the Joint Commission issued 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. 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.

As we have done with our previous surveys, we are pleased to share a summary of our 2012 survey performance, how we are responding, and the final report, which you can access by clicking on the link below. 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.

2012 Joint Commission Summary

I want to personally thank every member of our staff who did an extraordinary job showcasing our hospital’s commitment to Excellence Every Day—providing the highest quality, safest care that meets or exceeds all standards set by external groups and our own internal standards. The Joint Commission surveyors were captivated and inspired by your passion and skill.

Peter L. Slavin, MD





Peter L. Slavin, MD
President
Massachusetts General Hospital

 

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