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Regulatory Readiness Resource Guide for Licensed Staff

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

Readiness checkmarkChecklists & Reviews

In striving for Excellence Every Day, monitoring of current performance a commitment to continuous improvement creates an environment of safe patient care. The checklists below will help you and your staff assess your current performance relative to some key areas:



The Joint Commission logo

Caring Headlines (5/7/15)
The Joint Commission Visit
survey characterized by a mutual desire to improve patient care

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.”

Tuesday Take Away
    This week's featured topic: MOLST


Regulatory Readiness Resource Guide for Licensed Staff

Excellence Every Day Regulatory Readiness Resource Guide for Licensed Staff:

Patient Care Services Licensed Staff


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The Joint Commission logo
               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.

  GOAL 15: Identify patient safety risks

  Universal Protocol: Prevent mistakes in surgery                                                   return to top


If you have questions or suggestions related to the Regulatory Readiness portal, please contact Georgia Peirce at (617) 724-9865 or via email at

updated 11/6/15

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