April 20, 2007
To our Patients, Families and Visitors:
I am pleased to share the details of our recent review (January 2007) from the Joint Commission (formerly known as JCAHO). This independent body of experts evaluates and accredits about 15,000 health care organizations and programs in the country with a focus on improving the quality and safety of care. For more on the Joint Commission, I invite you to visit its website: www.jointcommission.org.
During each Joint Commission visit, surveyors are given complete access to a hospital and track very closely the care that is delivered to patients to ensure quality and safety. If a surveyor has a concern about the process of care, an “RFI” (Requirement for Improvement) may be noted.
Brigham and Women’s Hospital (BWH) had a very positive review during its January 2007 survey as the Joint Commission members lauded our hospital and staff for the transparency of our care process. The surveyors described our community as a group of extremely warm and caring professionals and noted, without exception, the extremely positive comments they received from our patients and their families. I am very proud of our teams. The surveyors notified hospital leadership immediately after the survey that BWH would remain fully accredited.
In our environment of transparency, we would like to share the Joint Commission’s findings at BWH. We view this feedback as a way to improve the care we provide for our patients and their families. To provide some context, no hospital is immune from “RFI”s; our hospital is no different than others around the country in that we are all seeking solutions to the same complex challenges that generate the “RFI”s. We all know that one is too many, but we also understand how this valuable information will challenge us to deliver a standard of excellence for which our hospital is known.
There are 265 hospital performance standards. Of these, Brigham and Women's Hospital received the following “RFI”s:
Critical Test Results
This category focuses on the time required to get test results from the lab to the patient’s nurse and doctor. The Joint Commission found that BWH was not consistently documenting the time it took to get the test result to the doctor.
BWH Action Plan: We have developed a program that now tracks this process. We have developed an education campaign around this action plan.
Pharmacy Review
This category focuses on pharmacy’s involvement in the care process. Our pharmacy is a key checkpoint in that process. The Joint Commission found that in a small minority of cases, the pharmacy had not reviewed a doctor’s medication order before the medication was given to a patient.
BWH Action Plan: We have implemented a plan where drug orders are reviewed by the pharmacy. This ensures safety for our patients.
Labeling Medications
This category involves removing a product such as a medication or solution from its original container and placing into another, possibly smaller container such as a basin or syringe. To ensure patient safety, once the product is removed from the original container and put in another container, that second container must be labeled immediately after the removal of the medication or solution.
BWH Action Plan: We have developed an education program to reinforce our policy with our care providers and are monitoring our efforts.
Medication Reconciliation
This category involves comparing patients’ home medications with medications that they receive in the hospital. This is to avoid any potential negative drug interactions and make sure that correct doses and medications are being prescribed, especially when the patient is discharged from the hospital.
BWH Action Plan: We are developing a computer program that will help doctors, nurses and pharmacists compare any drugs a patient may be taking at home with those the patient may receive at the time of hospital admission and discharge. Until the computer program is finalized a manual review process is in place.
Use of Restraints
Restraints are sometimes used to protect patients who may be agitated or need protection from unintended movements while they are in the hospital. The “RFI” reflects the need for more timely documentation by the treatment team when restraints are in use.
BWH Action Plan: We have developed a bedside reference sheet for the treatment that outlines the restraint policy and documentation requirements.
Access to Medical Gas Shut-Off Valve
This category focuses on clear access to these valves. The “RFI” notes equipment was located under some of these valves.
BWH Action Plan: We have moved equipment from under the valves; we are continually monitoring equipment storage.
Clutter
This is a challenge for most hospitals. As new technology is introduced to the care process, it takes up space. Our patient tower, built more than 25 years ago, faces the challenge of finding room for the new technology. We are anticipating that the opening of the Carl J. and Ruth Shapiro Cardiovascular Center will create some new space for our technology-based patient safety initiatives.
BWH Action Plan:We have created a program to identify equipment that is no longer needed on a daily basis and remove it to a storage area in order to create space.
Fire Exit
This category focuses on the need for clear signage for all fire exits.
BWH Action Plan: Fire exits now have signs that are clearly visible.
Fire Pump Testing
The category focuses on testing our fire pump weekly.
BWH Action Plan: We are testing the fire pumps weekly.
Thank you for taking the time to read through our report. Brigham and Women’s Hospital values the feedback we receive from the Joint Commission and we embrace the opportunity to learn and then improve upon our care, treatment and environment for our patients, their families, our employees and visitors.
Thank you,
Gary L. Gottlieb
President
Brigham and Women’s Hospital
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