Massachusetts General Hospital
2015 Joint Commission Survey Results


Dear Colleagues:

The survey team from The Joint Commission – the independent nonprofit that accredits and certifies more than 19,000 health care organizations and programs in the United States – has completed its five-day (April 13 to April 17, 2015) assessment of MGH’s hospital and laboratory sites. The survey team spent an equivalent of 51 days here, examining our patient care areas, facilities and laboratories. I thank all of you who took time from your daily work to speak with surveyors about the care we give at the MGH.

Surveyors were generous with their praise of our organization – the staff, facilities and the care we give our patients. “Phenomenal,” “superb,” and “best in the nation” were just a sampling of the adjectives we heard from surveyors. More than once, they called an MGH process a “best practice” and suggested we publish our way of doing things in the commission’s library of online resources for hospitals.

We strive for Excellence Every Day, but we know that we are not perfect, and The Joint Commission has identified some areas where they believe we could improve. They are as follows:

  • Record of care. The Joint Commission said that our home-grown medical record is, in most instances, excellent, however there were a number of documentation omissions. The Joint Commission team universally applauded our decision to move to the Epic electronic medical record and said they believe that many of these omissions will be avoided once the new record is in place.
  • Infection control. The Joint Commission recognized the tremendous efforts we have made in reducing hospital-acquired infections, but some further improvements were recommended in our high-level disinfection processes.
  • Environment of Care and Life Safety. The Life Safety engineer was exceptionally impressed with the cleanliness of our facilities. A small number of recommendations were made for improvements in the life safety and environment of care areas.

In the Lab Survey, the following areas were recommended for improvement:

  • Documentation oversights in proficiency testing areas.
  • Observed documentation deficiencies in receipt of critical values.
  • A small number of findings in quality system assessment requirements.

2015 Joint Commission Summary

This was a very successful survey. We go into each survey hoping for zero findings, but it is important to remember that the survey is not meant to be a pat on the back, but a learning opportunity.

In the closing, the survey leader said that despite their findings, all indications were that the patients at Massachusetts General Hospital were receiving excellent care. I thank everyone for their efforts this week, and of course, for practicing Excellence Every Day.


Peter L. Slavin, MD

Peter L. Slavin, MD
Massachusetts General Hospital


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