Accreditation

Don't Lose Sight of these JCAHO Changes

Accreditation Monthly, August 9, 2006

Dear Colleague,        

This month I have two "heads-up" messages for you regarding criteria for obtaining physician-to-physician consultation and laboratory service accreditation.

First, effective January 2007 MS.2.20 EP 4 (A) will require that "Consultation is obtained for the circumstances defined by the organized medical staff." As an "A" EP it will be very easy for a surveyor to test for conformance and mark you in noncompliance if no consultation criteria policy or similar document approved by the medical staff is producible.  My Greeley Company consulting colleague Bud Pate advocates this simple and effective policy language:

"Except when consultation is precluded by emergency circumstances or is otherwise not indicated, the attending Practitioner shall consult with another qualified Medical Staff member in the following cases:

  • when the diagnosis is obscure after ordinary diagnostic procedures have been completed
  • when there is doubt as to the choice of therapeutic measures to be used;
  • for high risk patients undergoing major operative procedures;
  • in situations where specific skills of other physicians may be needed;
  • or when otherwise required by the Medical Staff or Hospital policies."

And now my second "heads-up," is your clinical laboratory service accredited by JCAHO?

Are you aware that a poor showing (Conditional or Preliminary Denial of Accreditation) during your JCAHO laboratory survey affects your hospital in the same way?

Did you know there are four new JCAHO decision rules related to the laboratory's proficiency testing that affect the organization's accreditation?

Are you sure your laboratory is prepared for their JCAHO biennial lab survey?

Do you have laboratory-specific tracers that can pinpoint problem areas for lab services in your hospital?

Has a negative decision on your laboratory survey already affected your accreditation status?

Even if your lab is accredited by the College of American Pathology (CAP), have you checked to see if you are in compliance with the Transplant Tissue standards that were made mandatory for hospitals in July 2005?  (Prior to this date these standards were found only in the JCAHO Laboratory Standards Manual and thus may have slipped past your observant eye.)

If your answer to any of these questions sends a shiver up your spine or concerns you, we can help. Our Clinical Laboratory experts can help prepare your lab for its biennial survey as well as assist you with follow-up to a negative accreditation decision. With solid tips and a common-sense approach to meeting the standards, our laboratory experts can help your staff meet the JCAHO lab surveyor with confidence.

It may also be time for your hospital to schedule an Unannounced JCAHO Compliance Test-Run visit by one of our Greeley Company mock survey teams. 

If you would like more information on either of these services, please call Sandi Reen, Practice Manager, at 888/749-3054, ext. 3263, e-mail sreen@greeley.com, or visit us on the Web at www.greeley.com.

Our initial telephone consultation is completely free and without obligation.

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