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How does the new survey process involve my lab?

Accreditation Connection, October 31, 2005

In the past, labs had minimal involvement in hospitalwide JCAHO surveys, says Pat Thaxton, lab administrator at Long Island College Hospital/Continuum Health Partners in Brooklyn, NY.

Under the JCAHO's new method, any time a hospital patient's care or treatment involves lab services, the lab can be subject to scrutiny, says Thaxton, whose non-JCAHO accredited hospital lab went through a tracer survey.

Surveyors can assess a laboratory's performance under the tracer method from test ordering through the testing itself and reporting processes. The survey will also review quality control, instrument maintenance and calibration, proficiency testing data, and the competency of the laboratory staff.

During a hospital survey, the JCAHO will also want to see how the processes of the lab meld with those of other departments. For example, the lab procedure for reporting critical test values should coordinate with the hospitalwide process for notification of critical results.

Blood bank and point-of-care testing are also areas that surveyors could focus on under the tracer method. Glucose testing is a good example of a lab function that has moved into the general hospital under point-of-care testing and could direct surveyors' attention to the lab because the lab is responsible for the competency and quality of such testing, adds Thaxton.

Adapted from the October issue of Laboratory Compliance Insider.

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