July 15, 2005

JCAHO to survey lab areas

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has notified the MGH that a lab survey of the hospital's clinical testing areas will take place from Sept. 19 to Oct. 3. This 11-day visit will be conducted by one surveyor who will inspect the Pathology Service and any area of the hospital that performs tests. Visits will be made to the inpatient units, operating rooms and special function laboratories as well as potential visits to the WACC, the Yawkey Center for Outpatient Care, the MGH health centers and CNY.

Lab surveys, which are conducted every two years, also use the JCAHO's tracer methodology, a new process that surveyors use during hospital surveys to assess systems through "tracing" a patient's experience. With this method, a surveyor follows identified patients throughout their care experience, speaking with staff members who care for those patients along the way. In the case of the lab survey, test results could be "traced" back to a patient and his or her caregivers.

The lab surveyor could question any employee who orders clinical tests, collects specimens, reports or receives clinical results, acts upon clinical results or who packages, labels, transports or analyzes specimens. Employees who are preparing for this lab inspection should focus their efforts on areas and topics such as verification of patient identification, notification of critical lab results, reference ranges and procedures for point-of-care testing, tissue banking, as well as phlebotomy and transfusion procedures.

For more information about the lab survey, call Donna MacMillan at (617) 726-8887 or Dom Misiano at (617) 726-3858.