A I mentioned a couple of weeks ago, BIDMC had an unannounced visit from the Joint Commission. At the time, I promised you that I would publish the results of that review. Following is the email I sent to our staff today. Here again is the link to the full report.
As many of you know, we recently had a visit from the Joint Commission, the organization that accredits all of the hospitals in America. The surveyors from the Joint Commission spent several days here in intense review of our physical facilities, our information systems, and -- most importantly -- our actual delivery of care to patients. As is the current practice, this was an unannounced visit, with the surveyors showing up on a Monday morning with just a few hours notice. The people who came were excellent, thoughtful, and comprehensive. As I will discuss below, they found some things that needed improvement, but they also had many compliments for the hospital in general and for many, many of you in particular. They were struck by how many of you came up to them to explain what you were doing and to demonstrate our clinical approaches and advances.
I want you to have the advantage of their work product, so I have posted it on our website. Please read it. Here's the link: http://www.bidmc.harvard.edu/JC07_report. As far as I know, this is the first time that a hospital has made its Joint Commission report available to the entire staff and to the world at large. Doing so is consistent with our approach to quality and safety matters here at BIDMC. We believe that sunshine is the best disinfectant!
To summarize, there were three types of areas in which the surveyors asked us to make improvements: clinical process, infrastructure, and administrative. In all, they found eight areas for required improvements. I am not going to go through all of those here, since you can read them yourselves, but let me hit a few highlights as I see them.
First is medication reconciliation. We have the most advanced clinical support systems to help providers ensure that they know the full range of medications being taken by a patient. Our electronic medication reconciliation system enables any clinician, at every encounter, to review all the medications a patient is taking, then verify they are correct or modify them to indicate that the patient is not taking them. Additionally, we can record medications provided at an outside institution, document over the counter medications purchased at a drug store and even record medications with uncertain dosages that a patient reports receiving from other providers. All of this information is used to perform safety checks such as drug/drug, drug/allergy and drug/food interactions.
(By the way, in September we go live with a cutting edge medication history system that will display dispensed drug history from every pharmacy and insurance company in New England. This system, part of MA-Share e-Prescribing gateway, will check drug/drug and drug/allergy interactions among every medication a patient has ever received from any clinician in our region, including medications prescribed by Partners Healthcare, Lahey, Caritas, and private practices.)
But a system like this is only as good as it is being used. The Joint Commission surveyors found that there was uneven use of this powerful system by our doctors and suggested that we enforce it hospital-wide. We agree totally. While many doctors use the system daily, others have avoided it. This is probably understandable, in that some doctors like to be "early adopters' and others are a bit slower to utilize new technology. Over the coming weeks and months, we will make use of the system mandatory.
A second area is the history and physical exams that are performed on patients before surgery. Here, we had a certain system in place, but we learned during the survey that our approach was not quite in compliance with the current Joint Commission standard. Once the surveyors pointed this out, we immediately corrected it, and we believe we are now in conformance with the current standard.
A third area was the security of medications in our code carts, both on the floors and in the supply assembly areas. Certain medications need to be protected so they are not available and stolen or misused. We are fixing this.
On the infrastructure front, the surveyors found a variety of items. For example, some gas canisters were not properly secured. This is a true public safety hazard. If an unsecured gas canister falls and the regulator breaks off, the heavy tube can be an uncontrolled projectile. Another example is that several of our fire doors had gaps of greater than 1/8 inch between the door and the door frame. Again, a public safety hazard that we will fix.
The next step in this process is that we have 45 days to submit plans for required areas of improvement to the Joint Commission. We are also permitted to appeal the surveyors' report if we think that they were in error on one point or another. That sometimes happens because, notwithstanding good intentions, the surveyors cannot necessarily get a full picture of all items during a one-week visit. We are likely to appeal one or more of the areas that were found to require improvement. This does not mean we would avoid actually making improvements in those areas -- it would only mean that they would not be a formal requirement for our re-accreditation.
The upshot is this. We did very, very well. On average, the Joint Commission finds 10 or more requirements for improvement in their hospital surveys. We had eight. Our re-accreditation is secure. The areas in which they found us wanting were legitimate and proper, and it is our job to fix them. The good news is that we were not surprised. Most of the areas they pointed out were on our agenda to fix over the coming months as part of our continuous improvement efforts.
I have often said that, if the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public. I want to thank the hundreds of you who interacted with the surveyors in such an open and positive way during their visit, and to the thousands of you who were ready to do so.
Paul F. Levy
President and CEO