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Excellence Every Day

EXCELLENCE EVERY DAY PORTAL 

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REGULATORY READINESS
"promoting excellence every day"
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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, Director

Judi Carr, RN, MS, Staff Specialist

Karen Miguel, RN, Staff Specialist

Mary Ann Walsh, RN, Nurse Clinician


Magnet Recognition Journey Resource Guide

Joint Commission Regulatory Readiness Resource Guide

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:

Checklists

References


Tuesday Take Away
    This week's featured topic: Think F.A.S.T When You Suspect a Stroke

 

The Joint Commission logo
               2019 National Patient Safety Goals (NPSGs) for Hospitals

The purpose of the National Patient Safety Goals is to improve patient safety.
The goals focus on problems in health care safety and how to solve them.


  GOAL 1: Identify patients correctly

NPSG.01.01.01
Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

NPSG.01.03.01
Make sure that the correct patient gets the correct blood when they get a blood
transfusion.

  • Selected MGH Policies and Procedures Related to NPSG 1 (in Ellucid; internal access only):

  GOAL 2: Improve staff communication

NPSG.02.03.01
Get important test results to the right staff person on time.

 

  GOAL 3: Use medicines safely

NPSG.03.04.01
Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.

NPSG.03.05.01
Take extra care with patients who take medicines to thin their blood.

NPSG.03.06.01
Record and pass along correct information about a patient’s medicines. Find out what
medicines the patient is taking. Compare those medicines to new medicines given to the
patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.


  GOAL 6: Use alarms safely

NPSG.06.01.01
Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

 

  GOAL 7: Prevent infection

NPSG.07.01.01
Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

NPSG.07.03.01
Use proven guidelines to prevent infections that are difficult to treat.

NPSG.07.04.01
Use proven guidelines to prevent infection of the blood from central lines.

NPSG.07.05.01
Use proven guidelines to prevent infection after surgery.

NPSG.07.06.01
Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.

 

  GOAL 15: Identify patient safety risks

NPSG.15.01.01
Find out which patients are at risk for suicide.

 

  Prevent mistakes in surgery                                                    return to top

UP.01.01.01
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.

UP.01.02.01
Mark the correct place on the patient’s body where the surgery is to be done.

UP.01.03.01
Pause before the surgery to make sure that a mistake is not being made.

 

ADDITIONAL RESOURCES

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

updated 11/9/18

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