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After showing up unannounced and spending a week traversing BWH’s distributed campus, the team of surveyors from the Joint Commission came away impressed with the hospital’s commitment to delivering high-quality, safe care. BWH remains fully accredited following the triennial hospital survey.
The six-person survey team used the Joint Commission’s tracer methodology and followed dozens of patients’ medical records to approximately 45 departments and units throughout the Tower, Connors Center, Emergency Department, Pharmacy, surgery suites, 850 Boylston St., and Southern Jamaica Plain and Brookside community health centers. More than 250 BWH clinical, administrative and support staff were directly involved with the survey team, impressing the visitors with top-notch clinical practice, knowledge of hospital policies and adherence to national safety standards.
“It’s never easy to face scrutiny with such high stakes, but everyone at BWH demonstrated a commitment to patient safety and excellence and a willingness to share our dedication to our mission. All of that was reflected in the feedback we received from the Joint Commission,” said BWH President Gary Gottlieb, MD, MBA.
The Joint Commission’s accreditation report presented no surprises to BWH leadership and staff, as the hospital received high marks throughout the survey along with a few areas identified for improvement. Efforts are underway to improve equipment storage, address egress issues and implement fully medication reconciliation, for example.
The positive feedback far outweighed negative findings, said Janet Barnes, JD, RN, BWH’s executive director of Compliance and Risk Management. “It was clear to the surveyors that everyone at BWH takes pride in what we do and that we deliver care at a very high level,” Barnes said.
Surveyors commended BWH for perfect compliance with hand hygiene protocol, as every clinician washed his or her hands or sanitized them with Purell at appropriate times. “At an institution this size, that’s really unheard of,” Barnes said.
Nurses shined throughout the survey. “Every nurse was so accommodating and able to demonstrate expert clinical care skills, an intimate knowledge and understanding of BWH policies and a commitment to patient safety,” Barnes said. Diane Lancaster, PhD, RN, Nursing program manager for Quality, was instrumental in preparing the Provision of Care chapter in BWH’s Joint Commission effort.
In addition, the survey team was impressed with hospital leadership, especially as two members of the Board of Trustees, Chairman Marshall Moriarty and member Gretchen Fish, were on hand for the opening session Monday morning. A third board member, Mary Ann Tynan, joined for the leadership session on Friday.
Gottlieb praised Barnes, Gail Morrissey, manager of Clinical Compliance, and the entire Clinical Compliance team for months of preparation for the survey. In addition, Sharon Vitti, vice president of Clinical Services, played a significant role in preparing all of BWH’s ambulatory sites for readiness. Martha Burke, MSW, LICSW, director of Social Work and Clinical Services in Care Coordination, Mary Antonelli, RN, MSN, Nursing Quality program manager, George Player, director in Engineering and Dennis Tremblay, Environmental Affairs fire and life safety manager, were vital to BWH’s preparation, too.
“Congratulations to everyone at BWH, and thank you for all your hard work,” Gottlieb said. “It remains a top priority for all of us to maintain our commitment to delivering the safest and best patient care.”
The Joint Commission survey of BWH laboratories continued this week and is expected to conclude today. BWH Compliance in the next few weeks is gathering more information to share with Joint Commission as it prepares BWH’s final accreditation report. In addition, BWH must address a handful of areas identified for improvement with specific plans within 45 days.
During 2007, BWH remains subject to a one-day, unannounced validation survey. If that does not happen this year, BWH could be subject to a five-day, unannounced survey during 2008 into the first six months of 2009.