June 22, 2007

Joint Commission lab survey preparation

All MGH staff and employees — especially laboratory managers and staff, physicians, nurses and medical technologists — should be prepared for an unannounced Joint Commission laboratory survey to take place before Jan. 1, 2008. MGHers should consider it a hospitable inspection with a laboratory focus. The Joint Commission conducts its laboratory accreditation survey every two years. The inspection is independent from the recent hospital survey that took place in December. It centers on the inspection of processes and environments involved with lab testing, from point-of-care testing to laboratory work, with a focus on compliance with the 2007 Laboratory Services National Patient Safety Goals.

One Joint Commission surveyor will make a 12-day visit, or two surveyors will complete a six-day inspection. MGH employees will be alerted of the Joint Commission's arrival by their managers and broadcast e-mail. Surveyors will use the tracer methodology to follow work on patient care floors, in laboratories and throughout the hospital to trace compliance.

To prepare for the lab survey, the FYI information campaign will resume with the distribution of new posters and handouts — featuring a new FYI-laboratory logo — to all patient floors and laboratories. MGHers should use these documents to review important hospital activities, programs and policies, particularly those relevant to the Laboratory Services National Patient Safety Goals.

For more information about the Joint Commission Lab Survey, contact Donna MacMillan, director of Operations for Clinical Pathology, at (617) 726-8887 or dmacmillan@partners.org.