BWH Faces Continued Readiness Scrutiny
BWH staff impressed surveyors from The Joint Commission earlier this year with their commitment to delivering safe, quality care, but the scrutiny from state and federal regulators will continue.
The Centers for Medicare and Medicaid Services, or CMS, will conduct an unannounced, five-day survey of the hospital’s transplant services, and that survey will stretch across every transplant program at BWH, including heart, lung and renal. The transplant survey will happen sometime this year.
The Ventricular Assist Device (VAD) program also is open to an unannounced, two-day survey conducted by The Joint Commission between September and December. And the state Department of Public Health may conduct a survey of BWH’s infection control efforts at any time.
In addition to unannounced but expected surveys, BWH could be subject to an intense, two-week validation survey of The Joint Commission Survey findings. Mass General Hospital recently faced such a survey when CMS sent in a team of 16 surveyors to validate the findings from its recent Joint Commission hospital survey.
The CMS transplant survey will call for an exhaustive review of all transplant patient records—including patients now on the waiting list and patients on the wait list going back three years. Surveyors will interview staff and review electronic and paper records in depth. The surveyors will look to interview all staff affiliated with the transplant programs, including physicians, nurses and staff from Nutrition, Pharmacy and Social Work.
BWH last completed a CMS transplant survey in 2007.
The window opens in August for an unannounced biannual 10-day Joint Commission survey of BWH’s Department of Pathology, including the Clinical Laboratories Division. During the last lab survey, The Joint Commission 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. This upcoming survey will also include the recently opened Brigham and Women’s/Mass General Health Care Center at Patriot Place in Foxborough. The surveyor scrutinized the Clinical Laboratories, 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.
More than 100 BWHers, including medical and radiology technologists, laboratory managers and staff, the managers and staff in ambulatory labs, nurses and physicians, directly responded to questions from the Joint Commission surveyor.
Approximately two years ago, BWH completed its first-ever VAD Program accreditation survey with high marks. During the second such survey, which will happen between September and December, The Joint Commission will conduct a close examination of patient records through the tracer method.
BWH’s heart failure and VAD program has a strong history. BWH is the first hospital in New England to implant an LVAD, or left ventricular assist device, as a destination therapy, adding to the hospital’s substantial arsenal to treat heart failure. BWH’s VAD and transplant programs remain the busiest in the region.
“The triennial Joint Commission hospital accreditation survey is certainly the most time-intensive and farthest reaching of any survey we complete, but we must remain vigilant in our commitment to quality and patient safety as it can be put to the test at any time,” said Gail Morrissey, director of Clinical Compliance.