A perfect score.

For most clinical laboratories, biennial The Joint Commission surveys can be a time of trepidation. After all, there is much riding on these on-site evaluations--including the ability to operate as well as eligibility for reimbursement by Medicare. The Joint Commission surveys, intricate endeavors on their own, became further complicated in 2006, when they started being conducted on an unannounced basis--evolving from regularly scheduled evaluations into "surprise" checks. The laboratory at John T. Mather Memorial Hospital (JTMMH) in Port Jefferson, NY, recently completed its Joint Commission survey, and proudly reported a perfect evaluation--thanks in large part to the lab's streamlined processes, LEAN best practices, and a comprehensive automation solution.

Laboratory survey background

The Joint Commission, the national accrediting body for hospitals, laboratories, and other healthcare-delivery organizations, began conducting laboratory evaluations in 1979. Its goal has been to encourage safe, high-quality healthcare through a regular accreditation process that supports and evaluates the organization's quality and safety goals. The Joint Commission's National Patient Safety Goals reinforce that mission by providing a guide to reducing the accidents, miscommunications, and preventable medical errors that can compromise patient safety. According to CLIA'88 regulations, laboratory surveys must be conducted every two years. For labs within hospitals, this biennial survey is separate from the hospital's triennial survey.

Since the John T Mather Memorial Hospital laboratory was last surveyed in July 2004, the lab knew it was due for another visit in the summer of 2006. The lab's anticipated survey became reality a year ago on July 18, 2006, when the lab learned that the surveyor was not only on her way, but that the two-day survey process was to begin in less than an hour.

JTMMH is a not-for-profit hospital situated on the north shore of Long Island in Suffolk County (population 1.4 million). Since its establishment in 1929 as the first community hospital in its area, Mather has continued to meet the changing healthcare needs of the community by pioneering programs unique to a community hospital. Mather gained another first in February 2001 when it became the only hospital on Long Island, and the only community hospital in the entire northeast region, to be equipped with a state-of-the-art, fully automated, in-house laboratory robotics system.

Tracer methodology at work

As is now typical for The Joint Commission, the majority of the surveyor's time is spent conducting the survey using a tracer method of evaluation, looking at how care is being delivered, rather than on policies. This process involves "tracing" the patient's stay--from point of entry to post-discharge and all points in between. Surveyors examine how the patient-care standards are executed as they follow selected patients through the healthcare organization. The surveyors will visit patient-care settings and functional areas, guided by randomly chosen open records that relate to the priority focus process information.

For example, during The Joint Commission's triennial survey of the hospital two months before, the surveyor observed an ICU phlebotomist drawing blood samples from a patient who had also just completed a fingerstick for bedside glucose monitoring. The surveyor then followed that sample through the entire process--from positive sample identification through tube labeling at the patient's bedside, delivery to the lab, analysis, and reporting.

Next, the surveyor visited the lab, so she could witness what happened when a test was ordered from the floor in the laboratory. Specifically, she was interested in how the lab generates a barcode label, and how the process ensures positive sample identification and appropriate tube labeling at the bedside--using two unique identifiers as specified by The Joint Commission's National Patient Safety Goals. The surveyor also evaluated the time it took for those samples to arrive in the lab, as well as the turnaround time (TAT) for the test results to be reported back to the floor. The JTMMH process, from test order to reported results, required only 20 minutes. The surveyor then compared the patient's bedside glucose-monitoring results, which in this case was 318, with the blood sample result from the lab, which the lab reported back as 320.

"The Joint Commission surveyor was very impressed with the speed of the laboratory's turnaround time, as well as the close correlation between the results from the bedside glucose monitoring and the blood analysis from the laboratory," says Denise Uettweiller-Geiger, PhD, administrative director of the laboratory.

"With automation, we have a consistent, predictable testing process," she adds. "Once the bar-coded sample tubes arrive in the laboratory--as long as all the patient draw processes have been done correctly--there is virtually no error possible at that point because the automation process is a totally hands-free process."

TAT and Accuracy

Clearly, one of the keys to success for the JTMMH laboratory lay in its automation system, which includes pre-analytical processing via an automation system that performs sample login, decapping, centrifugation, and the sample sorting for the appropriate analyzers. Automated analysis is provided by two chemistry analyzers connected to the automation line allow automated retrieval for repeat and add-on testing. Autovalidation of normal results via automated analyzers, in conjunction with JTMMH's laboratory information system (LIS) and data-management software, validate normal results according to user-defined criteria and report the results directly to the LIS. At JTMMH, about 75% to 80% of results are autovalidated, a major factor in improved TAT. These features help the JTMMH lab meet its The Joint Commission patient-safety goals by automating patient identification, speeding up TAT, and increasing results accuracy.

Stellar results

At the end of the two-day process, The Joint Commission surveyor conducted an exit interview with hospital's senior management team and provided the survey results and his findings, which often include recommendations for meeting National Patient Safety Goals--specifically, proper patient identification, increased and effective communication between caregivers, as well as efforts to prevent medication errors. In the case of JTMMH, however, the surveyor informed the laboratory it had received a perfect evaluation, with no specific recommendations for improvement, no follow-up issues, and no supplemental items requiring attention.

"In the past, The Joint Commission assigned numeric scores to its surveys, but in 2004, the Joint Commission eliminated performance scores--shifting the focus from passing the exam to continuous operational improvement," says Geiger. "So even though we did not get a numeric score, the fact that The Joint Commission did not list any recommendations says that they found our lab's systems of safety and quality of care to be in full compliance with their standards and elements of performance."

Meeting more rigorous standards

"Today's regulatory environment is more complex than it used to be--and requires more stringent patient safety goals than ever before," says Geiger. "For me, this Joint Commission survey score was one additional affirmation of our recent transacted changes--the most important being our adoption of laboratory automation in 2001."

After installing a total automation system, the lab increased total testing volume by 82.6%, while maintaining the same number of lab employees. It also witnessed a 152% increase in revenue, a 17% decrease in cost per test, and a 79% reduction in drugs-of-abuse turnaround time.

"As part of our LEAN process-improvement efforts, we viewed the adoption of automation as a cost-effective way to improve our processes, increase productivity, and lower overall costs," says Geiger. "The automation system we selected offered the most comprehensive solution to our ongoing efforts, which are validated every day by keeping us inspection-ready at all times. We are very pleased with our latest The Joint Commission results, and attribute much of our success to our best practices and our automated processes."

Julie Bos is a freelance writer for Beckman Coulter. The instrumentation mentioned in this article includes the company's Power Processor (pre-analytic processing), its UniCel DxC 800 chemistry analyzers, and its DataLink DL2000 data-management software.