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Preparing your lab for an inspection.

Nothing strikes fear into the heart of a lab manager faster than hearing the JCAHO is coming to call. This laboratory conducted its own inspection first and sailed through the scheduled survey. After several years as a lab manager, you would think I'd have learned to take inspections in stride. Yet whenever a Joint Commission on Accreditation of Healthcare Organizations survey rolled around, I started woffying. I knew we were prepared, but the anxiety wouldn't go away-that is, until we began conducting a pre-survey dress rehearsal.

It is impossible to second-guess the JCAHO, but you can ease the stress by anticipating the surveyors' likely concerns. There is often no "right" or "wrong" way to comply with a particular standard, which makes it difficult to prepare uniform criteria. However, we find that following the presurvey checklist in Figure I gives us a game plan, gets everyone ready for the big day, and makes the ordeal less traumatic.

This approach works well at our 57-bed hospital. It has saved us a lot of headaches plus arnered glowing marks for the laboratory. The strategy is simple: Prior to a survey, I pull out the current JCAHO standards and play devil's advocate. With the checklist in hand, I conduct my own item-by-item inspection and ask "Are we doing this?" and "Is this up to date?"

The JCAHO has its idiosyncrasies. Standards can be misinterpreted, and sometimes the surveyor asks for data that aren't mentioned at all. Thus it's hard to make sweeping recommendations that will work in every lab. Still I think the following generic guidelines offer a solid foundation for setting up your own self-survey.

* Personnel file. Staffing is a crucial factor in the quality of lab testing, and I'm proud of my six laboratorians. To make sure the JCAHO is similarly impressed,I document their education, training, blood bank certification, and membership in professional organizations. We also file a copy of each employee's orientation checklist, which details the various lab skills mastered (Figure 11). The personnel folder also includes a complete job description (shown in part in Figure 111) and copies of the laboratorian's annual evaluations. All health records and any memos documenting, say, salary adjustments are also kept on file.

* General policies and procedures. Each laboratory (and hospital) has policies and procedures that each employee is expected to know and follow. Ours fill 14 manuals-all of them kept in my office and available to the staff at all times. Some manuals detail hospitalwide policies; others deal just with the lab. Although the specifics vary, the basic manual should cover certain generic information. Our "laboratory policy and procedure book" includes the expected general instructions, as well as more specialized guidelines for the different sections.

Many lab policies and procedures must be approved by the pathologist, the medical staff, or administration. Some require all three signatures, as is the case when our lab revises the Stat test menu. We also need joint approval of a blood supply source, reference lab, and critical values, as well as for guidelines stating who is permitted to administer test preparations or to accept phoned or verbal test orders.

Safety protocols must be noted, along with the hospital's safety committee recommendations in case of fire, tornado, disaster, or serious accident. The manual details spill and cleanup measures and lists the safety items to be kept close at hand, such as a fire extinguisher, fire blanket, overhead shower, and eyewash station. It also notes that our refrigerators must be labeled to show whether they are suitable for hazardous materials storage, another JCAHO requirement.

The manual also spells out infection control policies and procedures for both patients and staff. The employee section in our manual has policies covering accidental exposures, immunizations, health requirements, and the handling and disposal of toxic or biohazardous specimens.

In addition, there should be written policies for reagent preparation, labeling, dispensing, and storage. Other entries should include policies for the collection and storage of specimens and for dealing with unsatisfactory specimens. The protocol for notifying/ recalling patients for further testing also appears here.

Policies and procedures pertaining to blood or blood products must adhere to the current American Association of Blood Banks technical manual or standards and should be updated annually. The main lab manual also covers blood storage; the refrigerator's outside recorder, which monitors temperature fluctuations; returning and reissuing blood; and releasing blood in an emergency. It also addresses the JCAHO requirement for a remote alarm to monitor possible refrigerator malfunction when the blood bank is closed, since we have no third shift. The beeper spends the night at the nursing station. If the alarm sounds, the on-call technologist must come in to check it out.

The manual details our transfusion reaction policy and describes the plan for dealing with antibodies or incompatible crossmatches. Our size precludes antibody testing, so the manual explains that these specimens will be sent to the Red Cross in Nashville for an antibody workup. We adopt a case-by-case approach in the event of an incompatible crossmatch and follow the pathologist's recommendations.

* Written test procedures. Any test performed in the lab must have a written procedure. Although the format of our "section cookbooks" varies a good deal, certain general items should always be covered. For example, each procedural writeup must include detailed step-by-step instructions, references, and quality control. These manuals note specimen requirements and any necessary calibration or standardization, specifies the expected results or reference values, and spells out the section's backup procedures in case of equipment or reagent failure.

Our pathologist approves all new procedures and reviews all manuals annually. If a section hasn't added any new procedures or instrumentation in the last year, he just signs off on it. If something has changed, we point out the addition or revision for a careful read. The annual review form appears on the first page of each manual for quick reference.

* Preventive maintenance. This manual covers all lab equipment and includes a record of the procedures involved, documentation logs or sheets, frequency, and a log of service or PM calls. We have service contracts on most of our instruments, and the service reps generalsy come two to four times a year. We favor leasing, so the vendors are very good about staying on schedule. Each instrument has a log for recording its preventive maintenance history. A copy of all vendor PM paperwork goes into the manual.

* Continuing education. Regular CE is a vital aspect of laboratory work and can take many forms. Content is important and so is documenting participation of all lab employees-including the pathologist. Typical CE topics are quality assurance, safety, infection control, a review of inspection findings, and the results of proficiency testing. The JCAHO recommends doing a safety program at least once a year. We periodically address the other topics in our monthly CE sessions, although my veteran staff doesn't require much of a refresher.

*Pathologist consultation. Smaller labs that do not have a full-time pathologist must document all consultations. The consulting pathologist should visit the lab at least monthly, with a written report of his findings forwarded to the hospital CEO and medical staff. The lab must also establish a protocol for pathologist coverage between scheduled visits. Our pathologist is based at a hospital in Herrin, III. and travels the 50 miles to our laboratory once or twice a month. The rest of the time he is available as needed for consults, to meet with the medical staff, or to attend lab-related meetings. Pathololgy specimens are transported via courier for evaluation at his lab.

*Lab-nursing manual. We wrote this manual to ease communication and forge an understanding between the laboratory and nursing. The manual addresses such mutual concerns as specimen collection, Stat testing, results reporting, and signing out and reissuing blood. It explains our procedures and offers information on patient preps, reference values, collection times, and the transfusion policy.

Copies of the 205 -page manual are kept on the nursing floor, in the cardiac care unit, and in the emergency room. The director of nursing has a copy, and so do 1. This manual is a classic example of something that is not mentioned in the JCAHO standards, but that the surveyor will expect to see nonetheless.

* Quality control. Good QC is an essential element of accreditation and, again, is accomplished in different ways at different labs. All effective quality control programs must incorporate certain common elements, such as written guidelines, documentation on appropriate charts or graphs, frequency, acceptable limits, and the corrective action indicated when these limits are exceeded-remedial measures must be documented for any unacceptable result.

It is also important to demonstrate staff involvement in all areas and on all shifts. In my lab, that means running controls on the day and evening shifts-we don't do any testing after midnight. Proficiency testing is another must, and we meet this requirement through the College of American Pathologists surveys.

* Quality assurance. This is becoming a big concern. A wellconceived and well-executed QA plan documents that the laboratory is monitoring and maintaining quality patient care. The first step is to develop a departmental plan. The pathologists must be involved, and their participation documented.

We select various aspects of laboratory work and periodically evaluate these indicators against our own individualized standards to assess the lab's performance. Some indicators are checked monthly and others quarterly. For example, as shown in Figure IV, we monitor blood utilization, productivity, and physician satisfaction once a month and look at equipment, specimen handling procedures, and the correlation of lab results with patient diagnoses every three months.

When a problem-or a potential problem props up, corrective action and the outcome must be documented. We track the situation and summarize our findings in a quarterly report to the hospital's CEO and the medical staff. The CEO or quality assurance coordinator then presents our data to the governing board of directors.

The pre-survey walk-through takes time, and updating the manuals is tedious. But it's an investment worth making, and if you keep on top of the paperwork (and the filing), you only have to do this once. Upkeep is minimal, as long as you do it faithfully. The bottom line is that you have to compile the data for JCAHO anyway, and it's much wiser to be prepared.

The JCAHO surveyors love to ask questions. Often it seems that if they have 100 standards, they end up asking 200 questions! If you can show you're on the ball and produce whatever paperwork the surveyor requests, perhaps he won't ask all 200.

A JCAHO surveyor once told me that she could tell how an inspection was going to go within 15 -minutes. The pre-survey homework encourages you to collect the necessary documentation and builds confidence, which translates into ,credibility during the inspection. And this makes the experience a lot more constructive and a lot less confrontational.

This strategy has certainly proved to be a winner for our lab. We had our most recent JCAHO inspection a year ago, and the laboratory did very well-nary a deficiency . In fact, the inspector was so impressed with our job descriptions and in-service orientation records that he asked for copies for the Chicago headquarters. Though I can't say we will ever look forward to a JCAHO visit, our pre-survey inspections should keep sleepless nights to a minimum.
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Title Annotation:Joint Commission on Accreditation of Healthcare Organizations inspection
Author:Hefner, M. Scott
Publication:Medical Laboratory Observer
Date:Aug 1, 1989
Previous Article:Reequipping the lab: a brisk pace of renewal.
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