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BWH’s Department of Pathology, including Clinical Laboratories, Transfusion Services, Anatomic Pathology and areas performing point of care testing, completed an unannounced biannual 10-day Joint Commission survey Aug. 27.
“This year’s survey once again affirmed the highest caliber, state-of-the-art clinical care provided by our department,” said Milenko Tanasijevic, MD, director of the Clinical Laboratories Division. “This is undoubtedly a direct result of the unwavering commitment to service excellence and continuous quality improvement on the part of our clinical, technical and administrative staff.”
During the lab survey, The Joint Commission surveyor used tracer methodology to follow more than 50 patients’ records and their specimens through more than 30 laboratories and point-of-care testing sites throughout the main campus, 850 Boylston St., 221 Longwood Ave, Brookside and Southern Jamaica Plain community health centers, and Brigham and Women’s/Mass General Health Care Center at Patriot Place in Foxborough.
BWH received high marks in the final survey report, along with areas identified for improvement that the hospital will address.
BWH staff also impressed surveyors from The Joint Commission during the hospital-wide survey earlier this year with their commitment to delivering safe, quality care. But the scrutiny from regulatory agencies is not over yet.
Sometime this year, the Centers for Medicare and Medicaid Services, or CMS, will conduct an unannounced, five-day survey of the hospital’s transplant services. The survey will focus on patients receiving kidney, pancreas, heart and lung transplant services.
The CMS transplant survey will call for an exhaustive review of transplant program documents and medical records of patients receiving transplant services. The surveyors may go back as far as 3 years when requesting documents and patient records. Surveyors will interview staff and review electronic and paper medical records in depth. The surveyors will look to interview patients, families and staff affiliated with the transplant programs, including physicians, nurses and staff from Nutrition, Pharmacy and Social Work. BWH last completed a CMS transplant survey in 2007.
The Ventricular Assist Device (VAD) program also is open to an unannounced, two-day survey conducted by The Joint Commission between September and December of this year. Also, the Massachusetts Department of Public Health may conduct a survey of BWH’s Infection Control program at any time.