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In This Issue:
BWH is licensed, certified and accredited by several government and non-government organizations. While BWH voluntarily seeks the approval from a number of these organizations, most accreditations and licensures are the requirement of state and federal laws.
The Massachusetts Department of Public Health (DPH) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) are the two organizations that audit BWH most often.
In early 2005, a number of unannounced surveys will occur at both BWH and Dana-Farber Cancer Institute (DFCI). In order to ensure BWH’s success in these surveys, helpful information and staff resources can be found on the “Compliance Corner” page of www.bwhpikenotes.org.
BWH has modified its compliance monitoring processes to help staff remain ready at any time for a survey or audit. Should a surveyor arrive in any area, staff are reminded to notify the Office of Compliance and Risk Management at ext. 2-6442.
Important Upcoming Surveys Please note the following upcoming surveys and contact your supervisor or the Office of Compliance and Risk Management with any questions you may have on your potential role in each.
The JCAHO Clinical Lab survey will take place from January 25 to February 4, 2005. This survey will not resemble previous lab surveys. With the new Tracer Methodology (first implemented in the 2004 hospital wide JCAHO Survey), a large portion of the nine-day survey will take place in patient care areas and focus on lab test ordering, specimen collection, waived testing and the National Patient Safety Goals. • The DFCI JCAHO Hospital survey will take place in May or June of 2005. Because of the collaborative partnership between BWH and DFCI, BWH staff can expect portions of this survey to take place in BWH patient care areas. • The DPH hospital re-licensure survey will be taking place this winter or early spring, the dates for this survey have not yet been established. Much like what staff experienced with the new methodology used in the 2004 JCAHO Survey, the DPH will use a new set of standards, making this one of the most comprehensive surveys BWH has experienced in nearly a decade.
Introducing “DPH Survey Central” From now until the DPH re-licensure survey takes place, look for “DPH Survey Central” articles in future issue of BWH Bulletin. This is intended to help staff assess their readiness for this upcoming survey.