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Pleased to announce: Successful Joint Commission Survey!

By September 20, 2021October 13th, 2022Announcements5 min read

The Joint Commission logoLast week, we hosted The Joint Commission, a independent accreditation organization that upholds rigorous quality assurance and patient safety standards. We opt in to be reviewed by the organization, and we proudly consider it a pillar of our commitment to excellent patient care. The group reviews all healthcare organizations, including major hospitals. The Joint Commission visits every 3 years, and they do not announce when they will arrive until the morning of. We were pleased to host three surveyors last week.

Kiame Mahaniah

Kiame Mahaniah

A note from our CEO, Dr. Kiame Mahaniah:

It is with relief and pride that I announce that LCHC passed the Joint Commission survey with flying colors.  As always, we have a number of widely scattered issues to work on, but the survey confirmed what we’ve known: we provide excellent care, despite offering an impressively complex array of services.  The word used most often by our surveyors?  “Impressive.”  And the one aspect that impressed them the most? “How do you manage to hire such dedicated and engaged folks?”

On the last day of the survey, the team leader pulled me aside to emphasize how proud I should be of the work you do on a daily basis, and that I should truly boast of our performance.

Although there is always the risk of offending folks when I start mentioning names, I want to single out Elena Freydin, our Chief of Compliance, for leading us so successfully towards this goal over the last three years.   It takes a team, but success requires a capable captain. The surveyors were particularly blown away when they compared where we were three and a half years ago.  To have morphed into an institution that has clearly hardwired protocols in some of our more complex workflows was something they kept coming back to.

To pass a survey as rigorous as one from The Joint Commission, it takes sustained, daily work from all those involved.  So a shout-out to all the staff of Lynn Community Health Center.

For those of you who interacted directly with individual surveyors, a huge thank you.  To our dental department, we are particularly grateful for the hard work of not only changing their workflows three years ago, but maintaining an incredibly high level since then. Infection control for invasive procedures was the Joint Commission’s number one concern, and they were blown away by the dental staff’s understanding of the protocols and the rationale behind what they did.  Our SBHC teams deserve kudos for being the most subjected to repeated questioning: the integration and especially the BH work were both aspects the surveyors kept gushing about.  Our data team gets the award for most organized and most comprehensive set of presentations.  The surveyors were essentially overwhelmed by our lean journey, how precisely we follow certain data and how much we use to guide our daily operations.  I would be remiss if I didn’t mention that our Facilities staff were picked out for their excellence.

Even though I have mentioned a few responsible for outstanding performance, it took our village to raise this particular Joint Commission child.  I say it often at our organization town halls, and repeat it whenever I can: I am incredibly proud to be the chosen leader for such a hard-working, engaged and dedicated group of people.  We certainly have our foibles, our conflicts and areas where improvement is needed.  Yet, we can sometimes be so critical as to not realize how incredible of an institution we build every day:

  • our level of BH/PC integration is still not the norm out there, especially when outsiders realize it includes MAT and, especially, psychopharmacologic services
  • our collaborative relationship with SEIU 1199 and our combined promotion of staff issues is exceptional
  • providing 18 schools with therapy and psychopharmacologic services is unheard of
  • For our surveyors, it was the first time visiting a recuperative care center integrated within a health center
  • The size and depth of our substance use disorder treatment services continues to be jaw-dropping
  • We are now one of the only FQHCs left in Massachusetts to provide comprehensive obstetrical services
  • Our focus and execution on health equity is the envy of larger institutions
  • Our dedication to the daily improvement systems predicated by lean thinking continues to elevate our performance and intrigue our stakeholders

And last, but not the least, the pervasive role the health center has had in all matters COVID related…

To provide all these, at the quality level required by HRSA, NCQA and the Joint Commission is a feat you should all be extremely proud.  So, since we are on the heels of Yom Kippur, Mazel Tov! Congratulations for your hard work, and for being recognized for it.


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