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2013 Joint Commission Accreditation Report

2013 Joint Commission Accreditation Survey Findings
July, 2013


The Joint Commission, the organization that accredits all of the hospitals in America completed its survey at BIDMC and has issued its final report. The Joint Commission surveyors spent several days in intense review of BIDMC's physical facilities, information systems, and -- most importantly -- our actual delivery of care to patients.

As is the current practice, this was an unannounced visit by the Joint Commission, with the surveyors showing up on a Monday morning with less than an hour’s notice, 5 months shy of our 3-year survey cycle date. The people who came were excellent, thoughtful, and comprehensive. There were six surveyors who spent a total of 26 surveyor-days with us. In all, they talked with almost 200 of our staff members and visited 60 unique sites on and off campus.

We were evaluated on approximately 270 standards across topics such as Emergency Management, Infection Control, Performance Improvement, Patient Safety Efforts, Managing Medication, Environment and Life Safety, Leadership, Medical Staff Functions, Managing Human Resources and the Provision of Care.

The Joint Commission’s survey team has issued BIDMC a short list of recommendations for improvement, but they also had many compliments for the hospital in general, for many of our staff in particular and they acknowledged the design and meaningful systems that support quality and safety at BIDMC for our patients, our staff and our environment.

Consistent with BIDMC's practice and commitment to continuous improvement and transparency, action teams from across the organization are currently addressing each and every one of the recommendations and we have posted the Joint Commission's Accreditation Survey Report here on our website.

Our teams have been very busy at work to address the recommendations for improvement and to engage all levels of staff in workflow redesigns and education to revised policies to ensure quality care and a safe environment that meets Joint Commissions standards as well as BIDMCs own high expectations.

Click here to find out how to contact The Joint Commission.

Contact Information

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