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Serving Those Who Have Served:
Practical Approaches to Addressing the Invisible Wounds of War
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Striving for Excellence Every Day is part of the Mass General culture.
The Regulatory Readiness Portal is designed to support you in working toward this goal with a particular focus on expectations during external surveys. These periodic reviews assure the public that Mass General provides care based on evidenced-based practice and the most current standards for patient safety.
The Regulatory Readiness Portal provides easy access to information about key areas of compliance through National Patient Safety Goals resources and educational materials, a Tuesday Take Away archive, Regulatory Readiness audits, checklists, and more.
PCS Office of Quality & Safety staff are also available to help address questions about regulatory preparation and other patient safety issues. Please contact us at any time:
Colleen Snydeman RN, PhD(c), Director
Judi Carr, RN, Staff Specialist
Deb Frost, RN, Staff Specialist
Patti Shanteler, RN, Staff Specialist
Mary Ann Walsh, RN, Nurse Clinician
Exerpts & Observations:
“ It’s one thing to practice Excellence Every Day. It’s another to be able to articulate your practice in a way that conveys your knowledge, skill, and compassion. And it’s something else entirely to describe your practice to Joint Commission surveyors who are here to assess our ability to provide high-quality care in a safe, clean environment. But that’s exactly what staff throughout MGH did...”
RN Surveyor #1:
“There was no need to complete an Infection Control tracer because during my observations I saw perfect adherence to isolation practices, including the identification of patients, readily available personal protective equipment, and correct use of that equipment by all staff.”
RN Surveyor #2:
“Your clinical tracer program focusing on National Patient Safety Goals is remarkable. It’s very unusual for a large academic center not to receive some findings in this area.”
RN surveyor #3:
“Your behavioral health program is the best I’ve ever seen. Patients are treated with dignity and respect. Best in the nation.”
Life safety specialist:
“Your employees really know the fire procedures cold. Your buildings are exceptionally well-maintained. Everywhere I went was incredibly clean.”
“ It was overwhelming validation of our Excellence Every Day philosophy and a reminder of why I ‘m so grateful to work with the best clinicians, support staff, and administrators in the world.”
Excellence Every Day Regulatory Readiness Resource Guide for Licensed Staff:
2015 National Patient Safety Goals (NPSGs) for Hospitals
GOAL 1: Identify patients correctly
GOAL 2: Improve staff communication
GOAL 3: Use medicines safely
Goal 3 has 3 standards related to safe medication management: labeling of medications, anticoagulation therapy,
and medication reconciliation.
GOAL 6: Use alarms safely
GOAL 7: Prevent infection
Goal 7 has five standards related to preventing healthcare-associated infections.
- Policy Prevention of Healthcare Associated Infections (internal access only)
FOR STAFF: Infection Control: Dos and Don'ts
PATIENT EDUCATION MATERIALS:
GOAL 15: Identify patient safety risks
Universal Protocol: Prevent mistakes in surgery return to top
Medication Education Safety & Approval Committee
(MESAC-internal access only)
Infection Control Policy
(internal access only)
If you have questions or suggestions related to the Regulatory Readiness portal, please contact Georgia Peirce at (617) 724-9865 or via email at firstname.lastname@example.org.
Massachusetts General Hospital 55 Fruit Street, Boston MA 02114 / (617) 726-2000 / TDD: 617-724-8800