BWH Completes Joint Commission Survey with High Marks
Following the successful Joint Commission survey of the entire hospital and a separate survey of the laboratories, Brigham and Women’s Hospital is continuing in its “ever ready” mode and commitment to patient safety.
“Our adherence to our own high standards of care delivery and safety every day is the hallmark of Brigham and Women’s Hospital,” BWH President Gary Gottlieb, MD, MBA, said. “This commitment to excellence is not for our next survey, it’s for our next patient.”
Joint Commission surveyors came to BWH in late January as part of the unannounced survey. Traversing BWH’s distributed campus, the Joint Commission team came away impressed with the hospital’s commitment to delivering high-quality, safe care and announced at the conclusion of the survey that BWH remains fully accredited.
The six-person hospital 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.
The BWH Pathology Department gained high praise from the Joint Commission following its 10-day laboratory survey that concluded Feb. 9 with BWH Pathology remaining fully accredited. The lab surveyor used tracer methodology to follow approximately 50 patients’ records and their specimens through more than 30 laboratories and point-of-care testing sites throughout the main campus, 850 Boylston St., and Brookside and Southern Jamaica Plain community health centers. The surveyor scrutinized the Clinical Laboratory, Transfusion Services and Anatomic Pathology divisions of the Pathology Department and approximately 30 laboratory testing sites, including ORs, Cardiovascular Diagnostic and Interventional Center, the NICU and Interventional Radiology areas.
“It’s never easy to face such scrutiny, 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 Gottlieb.
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. There are 265 hospital performance standards, and of these, BWH received nine Requirements for Improvement or RFIs. Efforts are underway to reduce clutter throughout the organization and implement medication reconciliation, for example.
Janet Barnes, JD, RN, BWH’s executive director of Compliance and Risk Management, said, “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.”
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.
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.
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 that Monday morning. A third board member, Mary Ann Tynan, joined for the leadership session later in the week.
The Joint Commission conducts its laboratory accreditation surveys every two years independently of the hospital surveys. The two-week laboratory survey involved more than 100 BWHers, including medical and radiology technologists, laboratory managers and staff, the managers and staff in ambulatory labs, nurses and physicians, who directly responded to questions from the Joint Commission surveyor.
Michael Gimbrone, MD, chairman of Pathology, said, “The key to our success—and the Joint Commission surely made note of this—is our staff. Our medical technologists, clinicians and administrative laboratory staff are committed to excellence, and because of that, we have been able to establish and maintain an environment known for safety.”
BWH labs could face an unannounced, one-day validation survey anytime in the next year, and the next biennial 10-day survey—also unannounced—could come between June 2008 and July 2009.
During 2007, the hospital remains subject to a one-day, unannounced validation survey. If that does not happen this year, BWH would be subject to a five-day, unannounced survey during 2008 into the first six months of 2009.