Mass General makes its survey findings public

Openness helps ensure performance improvement

Why would a major, high-visibility facility like Boston's Massachusetts General Hospital (MGH) willingly share the findings of its final accreditation report from The Joint Commission — especially when the findings were not entirely positive? The answer, according to its quality leadership, is at once simple, but the process is complex.

"You're not going to improve on this stuff unless you are honest and get the word out about it," asserts Greg Meyer, MD, MSC, medical director and vice president of quality and safety for the Massachusetts General Physicians' Organization.

The staff learned in late 2006 in a memo from MGH's CEO Peter Slavin that "we did not do as well as we should have, and that there were a number of areas we just had to get to work on," notes Meyer. "When you have 20,000 employees, you know that e-mail is going out in the public domain."

And go out it did, in the form of coverage by the Boston Globe. Slavin's memo was cited in the paper as saying The Joint Commission found employees weren't washing their hands enough, weren't completely filling out medical records, and weren't correctly following medication reconciliation policies.

Faced with a choice

At that point, says Meyer, the hospital was faced with a decision. "The Globe had an immature approach to reporting on quality and safety," he notes. "We could have crawled under a rock, or we could have said, 'Why should we let a reporter tell our story?'"

MGH chose the second option. "This was an important story to our patients," Meyer explains. "If it wasn't told right it could have led to confusion, but we knew the truth ought to get out there because we needed to improve the situation."

And that's exactly what they did. Today, anyone who wishes to know the full story can go to the MGH web site,, and click on the link on the left-hand side of the home page that says, "Massachusetts General Hospital Joint Commission Findings."

Once there, the reader will see a letter from Slavin, then an MGH summary of The Joint Commission findings. In each case, it enumerates what was found, why it was important, what MGH is doing about it, and what progress they have made to date.

Oh, yes: For those who wish to wade through it, the Joint Commission's final report is also there in its entirety at the bottom of the page. "Frankly, we did not just want to put out the report, because it is so arcane many people would not have understood it," Meyer explains. "Our summary, by the way, does not pull any punches; it has all the data, and we will be updating it."

Parallel tracks

MGH is proceeding on two parallel tracks, explains Meyer. Not only is it pursuing its policy of public transparency, but it is working hard to address the issues raised by The Joint Commission.

"We thought it was important because, first of all, The Joint Commission is doing a better job than it ever has on a number of fronts," says Meyer, who used to be on the board. "They are measuring things that are really important to improving patient care; the unannounced survey is a better process, and things like the National Patient Safety Goals put really important challenges out there."

Since MGH is such a large facility, the process was quite involved. "We had the equivalent of 30 or so surveyor days, and the notion that all of us would get everything right in a short inspection is unrealistic," says Meyer. "To their credit, the Joint Commission released their initial findings, and then we had the adjudication process, where we had a chance to tell them what we think they got wrong. With that said, we knew as soon as the survey was done that we did OK — that we were even good — but not good enough."

The next step, then, was to interact with The Joint Commission to get to the truth. "This takes time; they required more data; there were additional chart reviews, and so on," says Meyer. "The final report is a reasonable reflection of the truth."

At the same time, Meyer knew there were some things "we just had to get to work on 'today.'" The dilemma was how can a small group of people sitting in a room fix things in an institution with 20,000 employees?

The answer is that they can't. "Everyone needs to get involved," says Meyer. That's where the policy of transparency proved invaluable. "I think it made all the difference," Meyer asserts. "The employees saw that this was serious, but that we were willing to work together and take our bumps. They also saw the commitment of leadership to put in the systems that were needed, and to align things so processes would get better."

The bottom line, he says, is that MGH is giving The Joint Commission, its patients, and the public "What they ought to have — better, safer care." As for the tedious process, Meyer admits, "a lot of my colleagues across the country might say they would not want to go through what we've gone through, but if it decreases hospital acquired-infections, then it's worth it."

[For more information, contact:

Greg Meyer, MD, MSC, Medical Director, Vice President of Quality and Safety, Massachusetts General Physicians' Organization, Boston, MA. Phone: (617) 724-9194.]