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Healthcare Quality Survey Gives Positive Results

Ruzanna Harutyunyan's picture

Results of the recent triennial survey of Cambridge Health Alliance by The Joint Commission, the not-for-profit organization dedicated to improving the safety and quality of health care in the US, were "outstanding," according to Dennis D. Keefe, CHA's chief executive officer, and "is the best report we've seen on CHA's operations since its inception."

The Joint Commission survey is an unannounced, intense review of hospital practices and no stone is left unturned in its surveys, which effect a hospital's accreditation. Seven surveyors from the Joint Commission spent a total of six days conducting the review of CHA's three main campuses and 20 ambulatory centers in September and October. Following the initial results, hospitals have 45 days to submit responses and provide data to support any areas of disagreement.

In its initial CHA review, the Joint Commission found 10 areas where it made recommendations to fully meet standards. None of the findings threatened accreditation but CHA administrators provided additional documentation to clarify CHA's performance and demonstrated sufficient compliance with standards. Earlier this month, CHA was informed that the Joint Commission accepted clarifications in seven of its findings and the three remaining items - covering such things as bedside procedure "time outs" and medication storage issues - may be reduced further still.

"Combined with the many other accolades and recognition of our achievement and improving quality and safety, the Joint Commission confirms that despite our well publicized and chronicled financial situation, we are focused on what's most important and I'm proud of everyone involved in sustaining our mission," Keefe said.

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This year, for example, CHA was one of 17 hospitals in Massachusetts recognized by Harvard Pilgrim Health Care for performance in the top 25 percent of hospitals nation wide on measures of quality, safety and patient experience. CHA's physician group also was an honor roll recipient for excellence in preventive and chronic illness care for pediatric patients.

In addition, in September 2008, MassPRO, the Federal Healthcare Quality Improvement Organization in Massachusetts, awarded CHA for its exemplary commitment to quality improvement in acute myocardial infarction, heart failure, pneumonia and surgical care. CHA received the award through its participation in work sponsored by the Centers for Medicare & Medicaid Services. Its collaboration with other area hospitals helped its participant group score in the top five in the nation. Lastly, for the 12 months through June '08, CHA was in the top 10 of the approximately 86 academic medical centers that benchmark data through UHC for aggregate pneumonia, heart failure and surgical care processes.

"It is important to remember what a unique organization CHA is," said Dr. Lucian Leape, a CHA board member and a national leader in safety standard advocacy for health care organizations. "It is spread over three campuses and 20 ambulatory centers over a wide geographic area yet the Joint Commission found a strong adherence to uniform standards of health and safety across the entire network. That's a substantial accomplishment and something to be proud of."

Keefe noted that The Joint Commission survey is always a tense time but that the entire staff responded this year with professionalism and pride. In addition, with the unannounced nature of the Joint Commission survey, CHA staff has shown that patient safety and quality is part of its culture and daily work.

"Perfection doesn't really exist in a review like this," Keefe said in a recent message to CHA's staff. "But I would venture that our results demonstrate that in terms of quality health care delivered to our patients in an organization of our size and complexity, we are continuing to pursue perfection in everything we do. It's a nice holiday message in the midst of all the negative news."