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Surprise check faults MGH quality of care

But hospital will get accreditation

Inspectors found numerous quality of care problems at Massachusetts General Hospital during a surprise inspection late last year, noting concerns about medication safety, inconsistent handwashing by caregivers, and incomplete medical records.

The organization that inspects hospitals does not make its findings public, but in a memo to staff, hospital president Dr. Peter Slavin outlined a series of issues raised by the inspectors, including staff neglecting to wash their hands before and after caring for patients; medical records lacking dates and times; and patients on pain medication for whom caregivers had not recorded whether their pain had improved. In other cases, staff failed to ask some patients about the medications they were taking before they were hospitalized, to ensure they would not be given drugs or treatments in the hospital that could cause a bad reaction.

Slavin described the findings as "a wake-up call of sorts" in his late-December memo, adding that the inspectors "had observed failures on our part to do some basic things."

Despite these issues, hospital executives said that they had been told yesterday that Mass. General would receive full accreditation from the Joint Commission, a private, nonprofit organization that evaluates health care facilities, but that the hospital must correct the problems. Hospital executives said that once they receive the commission's final report, they will take the unusual step of making it public.

The Mass. General inspection was its first since the Joint Commission began in recent years to change its system for assessing the quality of care in the nation's hospitals -- partly in response to criticism that its inspections were lax. Forty-three other hospitals and health care organizations in Massachusetts have been inspected under the new system.

Linda Murphy-Knoll, a Joint Commission vice president, said the organization appears to be uncovering more problems at hospitals since it began unannounced visits last year; before then, hospitals knew weeks in advance when inspectors would arrive, giving them time to prepare. Also, in 2004, the commission changed its inspections so that surveyors now spend most of their time following and observing care given to patients, rather than interviewing executives.

The Illinois-based Joint Commission evaluates more than 15,000 health care organizations and is the country's primary inspector of hospitals, nursing homes, and other medical institutions and programs.

When inspectors visited Mass. General in December, they found an undisclosed number of problems, which are called "requirements for improvement." The hospital then appealed some of those citations, which they believed were erroneous or were based on misunderstandings of hospital procedures; it also began to implement improvements in other areas. Inspectors returned to the hospital to update their information on Wednesday. As a result of the appeals process, the Joint Commission ultimately decided that the hospital was out of compliance in 10 areas, said Mass. General spokeswoman Peggy Slasman.

The hospital would not say how many problem areas the Joint Commission originally listed and declined to release the preliminary findings, but Mass. General could have come close to losing full accreditation.

If a large hospital like Mass. General is "not compliant" in 14 or more areas, the Joint Commission's policies state that it will grant the facility only "conditional accreditation." If the problems reach 20, the institution receives a "preliminary denial." Such a black mark can hurt a hospital's reputation with patients and donors, as well as affect its contracts with insurance companies, and it can lead Medicare to stop reimbursing the hospital for services.

In Massachusetts, the only hospital currently listed on the Joint Commission's website as having anything other than regular accreditation is the Northampton VA Medical Center in Leeds. The hospital has "provisional accreditation" based on an inspection last March, when inspectors found undisclosed problems in how staff cared for patients and provided medication. The hospital failed to provide evidence of improvement within 45 days of the visit, which resulted in the provisional status. A hospital spokeswoman would not provide details of the problems, but said the hospital is working on the issues.

At Mass. General, the hospital said it immediately put in place improvements in problem areas it did not contest, such as medication safety. Dr. Gregg Meyer, senior vice president for Quality and Patient Safety, said in an interview that the hospital made it clear to staff that they must find time to discuss with all patients the medications they were taking before entering the hospital, and review their medications again upon discharge.

The Joint Commission, whose governing board has long been dominated by representatives of the industries it inspects, has been the target of criticism about the validity of its evaluations. One of the main focuses of criticism were the announced visits, which allowed administrators to prepare their presentations for inspectors and scrub their facilities for weeks in advance.

Since the changes in the inspection system, the average number of deficiencies per hospital has jumped to seven from three, and the percentage of hospitals with conditional accreditation has risen to 2.8 percent from 1 percent.

Dr. Gary Gottlieb, president of Brigham and Women's Hospital, which was inspected in January, said in an interview that the process is more challenging than it used to be.

The Joint Commission's inspections are "no longer about putting things in pretty binders," said Jim Conway, a senior vice president at the Institute for Healthcare Improvement in Cambridge, a nonprofit research organization that consults with hospitals on patient safety initiatives. "They're good watchdogs now."

Others, however, still remain critical of the Joint Commission. "Our position is that inspections of hospitals and accreditation of them is too important to be left to a private sector organization that continues to be dominated by the industry," said Dr. Sidney Wolfe, director of health research for Public Citizen, a group founded by consumer advocate Ralph Nader.