JCAHO Visit Results in Accreditation- BWH Bulletin - For and about the People of Brigham and Women's Hospital
JCAHO Visit Results in Accreditation- BWH Bulletin - For and about the People of Brigham and Women's Hospital
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February 2, 2001
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In This Issue:
T’ai Chi classes
BWH Becomes a “Buddy”
BWH Docs are Top Boston-area Picks
JCAHO Visit Results in Accreditation
Who’s News
After-School Internships at BWH
Winter BWH Magazine available now!
African-American History Month
Parenting Workshop
Call for Scholar Nominations Special Insert
Thanks to the collective efforts of all staff at BWH, the hospital has obtained another three-year accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), according to a preliminary report from the regulatory agency. The final report is expected within two months. According to hospital leaders, last week’s JCAHO visit marked one of the most intensive surveys experienced by BWH. Surveyors conducted this year’s review with new, more stringent rules and new evaluation software. “With national news on medication errors and aggressive patient safety priorities of all accrediting agencies, this year’s JCAHO survey was particularly challenging,” said Matt Van Vranken, chief operating officer. “We appreciate the hard work of all staff in both preparing for JCAHO’s 2001 visit and in accommodating surveyor’s requests while they were on site.” Surveyors were particularly impressed with the unit-based visits, in which surveyors had the opportunity to speak to patient care teams from various clinical areas of the hospital, as well as staff members and patients. “We received feedback on how well members of patient care teams performed their jobs, how informed they were of policies and procedures and how defined, yet integrated, each of the members’ roles were. All of which, the surveyors observed, resulted in excellent communication and patient care delivery,” said Karen Nelson, director, Corporate and Regulatory Compliance at BWH. “One surveyor stated that the Department Directors Interview was the most impressive he’d ever conducted, in that each participant was able to describe how his/her work is dedicated to the hospital mission,” added Nelson. According to Nelson, JCAHO surveyors noted several areas in which BWH has excelled:
The advanced technology in Radiology;
The “exquisite use of space in the ORs”
How integral a role the pharmacy plays in patient care;
The exceptional teamwork exhibited on Tower pods and Connors Center units;
The state-of-the art Cardiac Catheterization Laboratory and MRT;
Infant security measures;
Pain assessment protocol and Pain Management Center;
Infection Control Program;
Commitment to performance improvement; and
BWH’s Passageway Program and new Code Procedures.
With the hospital and ambulatory surveys now completed, JCAHO surveyors will return to BWH in March to conduct the laboratory survey. Additionally, Health Care Financing Administration (HCFA), responsible for confirming the validity and correctness of the JCAHO process, could potentially visit BWH anytime in the next few months. “We encourage everyone to keep up the fantastic work and appreciate the staff’s continued efforts in accommodating the upcoming JCAHO lab survey and the possible HCFA visit,” said Nelson. JCAHO accreditation is voluntary for hospitals that receive federal funding for Medicare patients. Accreditation surveys take place every three years.