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The Joint Commission logo

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

Judy Carr, RN, Staff Specialist

Deb Frost, RN, Staff Specialist

Patti Shanteler, RN, Staff Specialist

Mary Ann Walsh, RN, Nurse Clinician

Corporate Compliance:

Claire Seguin, RN, Senior Manager

The Department of Public Health (DPH) conducts periodic, unannounced Infection Control surveys.

Resources to help you prepare:
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Joint Commission
Readiness checkmarkChecklists
& Reviews

Mass General is expecting a survey by The Joint Commission sometime beginning this spring. The checklists below will help you and your staff assess your ongoing performance relative to the National Patient Safety Goals and your readiness for a Joint Commission Survey. Each checklist contains key areas a surveyor will likely focus on while in your unit/department.

Regulatory Readiness Reviews
Tools & Strategies for Independent Unit-based Joint Commission Reviews
(internal access only)
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Regulatory Readiness Reviews (R3) Schedule
(internal access only)
Click here

Joint Committion FAQ Video
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Joint Commission Calendar
(internal access only)
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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



Glossary of Terms

Medication Education Safety & Approval Committee
(MESAC-internal access only)

Blum Patient and Family
Learning Center

Infection Control Policy
(internal access only)

Regulatory Readiness

Magnet @ MGH

MGH "Excellence Every Day" site

MGH Center for Quality & Safety

PCS Office of Quality & Safety

Treadwell Library



Agency for Healthcare Research
and Quality (AHRQ)

American Hospital Association

American Nurses
Credentialing Center (ANCC)

Centers for Disease Control
and Prevention (CDC)

Institute for Healthcare Improvement (IHI)

Institute of Medicine (IOM)

Joint Commission

National Committee for
Quality Assurance (NCQA)

National Database of Nursing Quality Indicators (NDNQI)

National Patient Safety Foundation




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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 2/24/15

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