From left: Xiaojie Liu, of Biomedical Engineering, and Brenda Griffin, of Nursing, at BWH’s Joint Commission Readiness Fair last September.

One surveyor from The Joint Commission (TJC) stated that “the heart of health care beats at the Brigham.”

Others lauded Watkins Clinic staff for “outstanding work and documentation” and their strong knowledge around process.

When a surveyor asked Liljana Zheku, a unit coordinator on Shapiro 9 East, about the purple sticker on her ID badge and if she was required to get the flu shot this season, Zheku responded by saying that she received flu vaccine because it protects patients and employees. The surveyor was impressed by this and later praised Zheku at a debriefing session.

Through these interactions and observations and many others, BWH showcased its commitment to patient safety and excellent care during TJC’s 2016 review, which was conducted earlier this month.

“We want to extend our sincere gratitude to the many people across our institution who helped us prepare for this visit,” said BWHC President Betsy Nabel, MD, on behalf of leadership. “Your commitment to our patients and families are evident across our distributed campus every day, always guided by our mission of delivering the highest standard of care to everyone we serve.”

During their five-day visit, surveyors used the tracer methodology, a means of evaluation in which surveyors select a patient and use that individual’s record as a roadmap to assess an organization’s compliance with certain standards and its systems of care and services. Surveyors visited many locations across BWH, from the Emergency Department, NICU, Tower and Shapiro Center to Pharmacy, Food Services and ambulatory practices, including Foxborough and Brookside Community Health Center.

Surveyors were eager to learn more about BWH’s Centering Pregnancy Program—a partnership between the Center for Community Health and Health Equity and the Midwifery Service that combines health assessment, education and support in a group setting for women receiving prenatal care at three BWH obstetric sites. Surveyors were also interested in BWH’s primary care population health management efforts and were impressed with Pharmacy’s management of a complication of heparin therapy—a blood thinning treatment—and the cost savings associated with this initiative.

One of TJC’s responsibilities is to make sure hospitals abide by Centers for Medicare & Medicaid Services (CMS) conditions, including physical environment, which TJC refers to as “life safety and environment of care.” In the environment-of-care evaluation, the surveyor team found BWH’s standards overall were “excellent.” However, with nearly 3 million square feet of buildings on campus, some of which are older facilities not designed for today’s medical equipment demands, 13 minor issues were observed in the inpatient Tower in particular. These issues—which included oxygen cylinders not in their holders, and carts, equipment or beds temporarily positioned in front of electrical panels and medical emergency shut-off valves—resulted in a finding that will require correction and a return visit by a TJC surveyor to confirm compliance. This finding does not impact BWH’s CMS certification or TJC accreditation.

“With the help of Engineering and Support Services, BWH has a mitigation plan in place; in fact, many of the issues were corrected as they were identified,” said Kelly Doorley, director of Clinical Compliance. “We will correct all of these issues within the 45-day timeframe. We appreciate all of your support in ensuring we stay compliant.”