Hospital striving to boost its score: Mass. General lost points in ’06 review

Press Releases, November 18, 2008

Massachusetts General Hospital, which fared poorly in its last inspection by a national accrediting agency, is getting ready for the group's next visit, which could come at any time within the next 13 months.

In preparation for the unannounced inspection, the hospital recently hired consultants to perform a mock accreditation survey and is implementing new training and educational procedures. In a recent e-mail to staff, Dr. Peter Slavin, Mass. General's president, said the survey showed some areas still need improvement and must be addressed "immediately."

Slavin said the hospital has to make sure staff members better follow "universal protocols," or sets of instructions for individual procedures; ensure that patients have physicals 24 hours before surgery; improve the documentation of anesthesia and sedation procedures; and more closely monitor patients who are in pain.

The hospital has also begun an internal communications program, called Excellence Every Day.

To receive payment from the government and insurers, hospitals are required to pass accreditation standards administered by several groups. The best known is the Joint Commission, of Oakbrook Terrace, Ill., which surveys 15,000 hospitals and other healthcare institutions each year, including Mass. General.

After the Joint Commission's last inspection of the hospital, in December 2006, it was cited for failing to comply with 10 requirements. Problems included inadequate hand washing, sloppy medical record keeping, and failure to properly interview patients about their drug regimens.

The Joint Commission previously gave hospitals advance notice of inspections, allowing them months to prepare. That practice was halted in 2006, partly in response to criticism that the policy favored hospitals, which pay fees to the commission. Hospitals are inspected once every three years, so while Mass. General doesn't know when the next inspection will be performed, it is expected by the end of 2009.

"The real challenge is to recognize that it's not about being ready for the Joint Commission to do a survey, it's about how to be ready for the next patient," said Dr. Gregg Meyer, the hospital's senior vice president for quality and safety.

The mock survey was conducted by Greeley Co., a hospital consulting firm in Marblehead. It found that while there is perfect compliance with universal protocols in operating rooms, throughout the entire hospital the step was only followed 84 percent of the time, Meyer said. In conducting a universal protocol, doctors and nurses review an upcoming procedure, make sure they have all the necessary supplies, and come to a "full stop," in which everyone stops what they're doing and makes eye contact before proceeding.

Starting next year, a series of meetings and computer-based training with doctors will reinforce the necessity of the step, Mass. General officials said.

More hospitals are adopting Meyer's approach, in which compliance with quality and safety measures is a daily effort, not a special event geared to an inspection once every three years, said Jim Conway, senior vice president of the Institute for Healthcare Improvement, a Cambridge nonprofit that promotes new ways to improve patient care.

"Massachusetts General is going through something we call constant survey readiness," said Conway. "Most smart and effective organizations do this constant survey readiness to keep themselves in compliance with Joint Commission standards all the time."

Conway also downplayed the significance of the Mass. General deficiencies noted in the last inspection.

"If you get a perfect score," he said, "it wasn't a good survey."

On the Joint Commission website, two Massachusetts hospitals are listed as having "conditional accreditation," which means they are "not in substantial compliance" with the commission's standards and are required to undergo a follow-up survey. During a January inspection at Heywood Memorial Hospital in Gardner, the problems found included failure to give other healthcare providers and patients complete lists of medications upon transfer or discharge.

Following a September 2007 inspection at Charlton Memorial Hospital in Fall River, part of Southcoast Health System, the commission said the hospital needed to improve its procedures for preventing infections, labeling and storing medications, and overseeing food preparation for patients.

Jeffrey Krasner can be reached at

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