Following its regular triennial review for national reaccreditation, the MIT Medical Department was granted accreditation with commendation-an honor bestowed on less than four percent of approximately 1,800 hospitals surveyed each year.
This fall, the department was inspected by representatives of the Chicago-based Joint Commission on Accreditation of Health Care Organizations, which conducts voluntary inspections, over a three-year period, of 5,300 hospitals and 275 to 300 free-standing clinics in the United States, said Dr. Bruce Biller, chairman of the MIT department's Quality Assurance Committee and an endocrinologist on staff here.
About 80 percent of hospitals in the country undergo review every three years by the JCAHCO. That process includes a site visit and a review of administrative procedures, said Dr. Biller, who also serves as a reviewer of other facilities for the organization. Although it serves far more outpatients (about 140,000 visits per year) than inpatients, the MIT Medical Department was evaluated according to the more rigorous hospital standards rather than as a clinic. This is because the department has an 18-bed hospital unit and also because that standard is required for facilities that receive clinical research grant money from the National Institutes of Health, he explained. A team consisting of two physicians, an administrator and a nurse spent two days at MIT and compiled rankings on thousands of standards.
"It's an opportunity for us to be examined objectively and extensively by a group of people looking at health care organizations that span every description from ivory-tower tertiary care facilities right on down to the smallest community hospital," said Dr. Arnold Weinberg, MIT's medical director.
The outcome of the review for a hospital can be non-accreditation, conditional accreditation (meaning it may continue operating but must act quickly to correct substantial problems), accreditation or accreditation with commendation, a new rating that was created in 1991.
The highest of the four ratings indicates that the reviewers found no significant flaws requiring remedial action. "It's really an amazing accomplishment" for MIT, Dr. Biller said. "It's highly unusual to have none. We're real happy with our report card."
Surveyors made only a few minor recommendations, such as improving documentation on the daily checking of medications in the pharmacy's emergency cart, Dr. Weinberg said. "There was no issue of direct care where there were any deficiencies noted of any type," he said.
The MIT Medical Department was one of four medical facilities in Massachusetts and one of only two in greater Boston to rate an accreditation with commendation, the other being Massachusetts Eye and Ear Infirmary, Dr. Biller said. Last year, 3.7 percent of facilities surveyed earned that rating, and the figure is projected to be about 3.9 percent this year, he added.
Since the MIT Medical Department was last re-accredited in 1990, administrative improvements have been made in areas such as implementing and documenting an infection-control program, and documenting the appointments and credentialing of staff members, Dr. Biller said.
In the future, the department will work to maintain and improve communication with patients about the need for protective immunizations and routine health screenings, in keeping with its role as a health maintenance organization, Dr. Weinberg said. The department will also continue efforts to have students make maximum use of its services, since some don't pay as much attention to routine health care as much as staff members and their families do, he added.
A version of this article appeared in the December 1, 1993 issue of MIT Tech Talk (Volume 38, Number 16).
