Holding Gains from JCAHO

Since receiving a stellar review from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) last November, BIDMC continues to hold the gains made for last year’s survey.

Ken Sands, MD, vice president and medical director of health care quality, says, “People from across BIDMC pulled together to ensure that our day-to-day work environment met our own high standards, as well as those of JCAHO — particularly the concerns identified by JCAHO’s National Patient Safety Goals.”

One way BIDMC is holding onto its JCAHO gains is through the Partnership for Achieving Continuous Excellence — or PACE — program. Once a month, representatives from this multidisciplinary program visit patient units to monitor safety requirements and educate staff about ways to continuously improve compliance.

BIDMC has also successfully integrated JCAHO requirements into care processes. For example, before any surgical procedure, JCAHO standards require that the surgeon take a “Time Out” to conduct a final verification of the patient, diagnosis, procedure and procedure site. This is now followed for all procedures, such as radiology.

“Before a CT Scan or ultrasound guided procedure, everybody in the procedure room, including technologists, nurses, residents and the attending, participates in a “Time Out” to verify the patient’s ID and exactly what procedure we will be doing. We verify the site of entrance, the organ to be biopsied or drained, and we confirm what kind of sample needs to be obtained and where the sample will be sent,” explains Jonathan Kruskal, MD, PhD, chief, abdominal imaging, radiology.

Going forward, JCAHO surveys will be unannounced or conducted with very little notice — making it more vital than ever for hospitals to have the appropriate procedures in place.

— Lori Howley

BIDMC’s not the only hospital to pass its JCAHO review with flying colors. Last month, BIDMC's community partner, Beth Israel Deaconess Hospital-Needham, matched this feat when JCAHO surveyors found BID-Needham in compliance with the approximately 500 JCAHO standards. JCAHO also gave BID-Needham a perfect score on its seven National Patient Safety Goals. Congratulations to the staff at BID-Needham!