September 16, 2005

Lab services under the microscope:
JCAHO lab survey coming next week

Many MGH employees and staff who are involved with lab functions have been busy preparing for the Sept. 19 through Oct. 3 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey of the hospital's laboratory services. The scope of the survey will include inpatient and outpatient areas and the Emergency Department, in addition to Pathology Services and other areas that perform lab tests. Employees who are preparing for this inspection should focus their efforts on areas and topics such as verification of patient identification, reference ranges and procedures for point-of-care testing, tissue banking, phlebotomy and transfusion procedures.

While this survey will be focused on lab services, MGHers should keep in mind that the JCAHO surveyor will be looking at standards that are included in the hospitalwide survey. For example, all employees should wear their ID badges at all times.

In addition, the JCAHO surveyor will be using the tracer methodology, a new process that assesses 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. This means that any employee could be interviewed by the surveyor during the lab inspection.

Below are some reminders of what employees should be prepared for during the lab survey.

Remember these patient safety goals:
• Improve accuracy of patient identification — use two patient identifiers.
• Improve effectiveness of communication among caregivers. Particularly when reporting critical lab results, staff should use the read-back system.
• Improve the safety of medications.
• Reduce the risk of health-care-associated infections. Specifically for the lab survey, proper hand hygiene should be used for specimen collection or point-of-care testing.
• Accurately reconcile medications across the continuum of care.
• Reduce the risk of patient harm resulting from falls.

Review of space for environment of care issues:
• Make sure that fire exits are accessible.
• Needle disposal boxes should be emptied and correctly placed for safe and easy access.
• All specimen tubes and point-of-care testing kits should be checked for dates of expiration.
• Sprinkler heads should have 18 inches of clearance above any storage.
• Hallways should be cleared of any clutter.
• Employees should be reminded that no smoking is permitted in hospital buildings or on hospital grounds.

For more information about the lab survey and the 2006 hospital survey, visit
the JCAHO website at www.massgeneral.org/jcaho or call Donna MacMillan at (617) 726-8887 or Dom Misiano at (617) 726-3858. Another helpful resource for the lab survey is the Pathology Service Laboratory Handbook located at mghlabtest.partners.org.