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In This Issue:
Official Accreditation BWH has submitted its Measures of Success report, as required by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), following the February 2004 Survey. This required follow-up report 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.
Moving Forward This year marked the first in which JCAHO conducted surveys using a Tracer Methodology. This new method was established to allow for a clearer picture of how institutions provide care. 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, prompted BWH to revisit its compliance monitoring.
As a result, the BWH PREPAIRE Team has been working to restructure the current PREPAIRE Audit process. The redesigned PREPAIRE Audits will take place over the course of a year on six designated “Tracer” Days. These 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.
The first “Tracer” day is Tuesday, November 16. For more information on Compliance issues, visit www.bwhpikenotes.org and look for “Compliance Corner” on the left side of the homepage.