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2016 Joint Commission Accreditation Report

May, 2016


The Joint Commission, an organization that accredits hospitals in America, completed its triennial survey of BIDMC in May 2016. Surveyors spent several days reviewing BIDMC's systems, processes and structures which are essential to delivering the highest quality of care for our patients within a safe environment.  

Throughout the accreditation visit the surveyors were complimentary of the hospital in general, as well as the dedication and compassion of our staff.  They acknowledged the design and meaningful systems that support quality and safety at BIDMC for our patients, our staff and our environment. 

The Joint Commission’s survey team provided BIDMC with a short list of recommendations for improvement.  In response and consistent with BIDMC's practice and commitment to continuous improvement and transparency, action teams from across the organization engaged in process redesigns, policy revisions, and staff education to ensure improved quality of care and a safe environment that meets Joint Commission standards as well as BIDMC's own high expectations for our patients, our staff, and our visitors.  

In summary, teams have worked over the past few months to address the following: 

Joint Commission Domain            BIDMC Improved:
Care of the Patient / Patient Rights
  • Clarity in communication for prescribing and administering medications.
  • Capture of documentation which accurately reflects a patient's care and treatment.
  • Processes for Food services and Interpreter services.
  • Policy for clarifications to record consent for specific procedures.
Environment of Care / Life Safety
  • Environmental safety risks and fire hazard mitigation strategies.
  • Processes for ongoing maintenance of medical equipment.
  • Reduction in risk of infection associated with medical devices.
Human Resources
  • Processes for orienting staff and assessing competency.

 

 

 

 

 

 

 

 

To read the full Joint Commission Accreditation Report click here.  

For information about how to contact The Joint Commission click here.

 

 

Contact Information

Silverman Institute for Health Care Quality and Safety
Beth Israel Deaconess Medical Center
330 Brookline Ave
Boston, MA 02215
617-667-1325