Dear Colleagues:

I am pleased to report that BWH has received its official notification of accreditation from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

This followed the hospital’s recently submitted Measures of Success report, required as a follow-up to the February 2004 JCAHO Survey and detailed BWH’s measured success of four improvement plans based on Survey findings. The measurement data indicated the appropriate level of improvement for BWH to maintain its standing of full JCAHO accreditation.

This year marked the first in which JCAHO conducted surveys using a Tracer Methodology. Aside from new methodology, all future JCAHO surveys will be unannounced. These changes, along with more frequent visits from other regulatory agencies such as DPH, EPA and FDA, have prompted BWH to revisit its compliance monitoring.

We now need to be prepared to prove and discuss how we meet regulations at anytime.

The Compliance and Risk Management Department, under the auspices of Karen Nelson, will take the lead on more regularly monitoring hospital wide compliance. One tactic to help with this initiative will be “Tracer” Days. The first of these was conducted in mid-November and others will follow, especially in light of a Department of Public Health Survey, due to take place unannounced prior to February 2005. “Tracer” days will consist of mock patient tracer audits in both inpatient and ambulatory areas. A medical record review will also take place in the various patient care areas, as well as an analysis of environment of care, infection control and occupational health issues.

Please take note of critical information and resources that are conveniently available to us on www.bwhpikenotes.org. “Compliance Corner,” found on the left side of the homepage, will direct clinicians to an assortment of compliance related news and resources that will assist us all to be better prepared to handle various audits.

Sincerely,

Andy Whittemore, MD
Chief Medical Officer