September 21, 2007
MGH lab services
under the microscope for Joint Commission lab survey
On Sept. 17, two Joint Commission surveyors completed the hospital's unannounced laboratory survey following a six-day inspection of all aspects and environments involved with lab testing at the MGH — from point-of-care testing, tissue banking, phlebotomy and transfusion procedures to other lab-associated work and settings. As part of the inspection, the surveyors completed proficiency testing reviews at the health centers, core labs and areas such as Microbiology, Molecular Diagnostics, Immunology and Cytology to assess the reliability of lab tests performed at these locations. In addition, they completed site visits at all MGH laboratories, including those in patient care units and other sites where tests are performed.
Using the tracer methodology, the Joint Commission surveyors also followed patients' experiences at the hospital, speaking with staff members who were caring for the patients along the way. Lab test results were then "traced" back to the patient and his or her caregivers. All employees — inside and outside of labs — were prepared to be interviewed by the surveyors during the inspection.
Several of the National Patient Safety Goals (NPSGs) that were a focus of this year's survey included improving the accuracy of patient identification, improving the effectiveness of communication among caregivers and reducing the risk of health care-associated infections.
"The survey was thorough and covered virtually all laboratory areas," says Maryanne Spicer, director of Corporate Compliance. "At the end of the survey, the team reviewed areas that need improvement during a closing meeting with all laboratory staff. The final report, however, is not made available until it is reviewed at the Joint Commission central office. We expect this to occur within the next several days, and then we will receive a final report of the survey findings. Many people were involved in this year's survey. Thank you to all who participated."
The Joint Commission conducts its laboratory accreditation survey every two years. The inspection is independent from the recent hospitalwide survey that took place in December.
A complete list of NPSGs is available at intranet.massgeneral.org/jointcommission/. For more information about the Joint Commission lab or hospitalwide surveys, contact Spicer at (617) 726-5109 or mspicer@partners.org.
On Sept. 17, two Joint Commission surveyors completed the hospital's unannounced laboratory survey following a six-day inspection of all aspects and environments involved with lab testing at the MGH — from point-of-care testing, tissue banking, phlebotomy and transfusion procedures to other lab-associated work and settings. As part of the inspection, the surveyors completed proficiency testing reviews at the health centers, core labs and areas such as Microbiology, Molecular Diagnostics, Immunology and Cytology to assess the reliability of lab tests performed at these locations. In addition, they completed site visits at all MGH laboratories, including those in patient care units and other sites where tests are performed.
Using the tracer methodology, the Joint Commission surveyors also followed patients' experiences at the hospital, speaking with staff members who were caring for the patients along the way. Lab test results were then "traced" back to the patient and his or her caregivers. All employees — inside and outside of labs — were prepared to be interviewed by the surveyors during the inspection.
Several of the National Patient Safety Goals (NPSGs) that were a focus of this year's survey included improving the accuracy of patient identification, improving the effectiveness of communication among caregivers and reducing the risk of health care-associated infections.
"The survey was thorough and covered virtually all laboratory areas," says Maryanne Spicer, director of Corporate Compliance. "At the end of the survey, the team reviewed areas that need improvement during a closing meeting with all laboratory staff. The final report, however, is not made available until it is reviewed at the Joint Commission central office. We expect this to occur within the next several days, and then we will receive a final report of the survey findings. Many people were involved in this year's survey. Thank you to all who participated."
The Joint Commission conducts its laboratory accreditation survey every two years. The inspection is independent from the recent hospitalwide survey that took place in December.
A complete list of NPSGs is available at intranet.massgeneral.org/jointcommission/. For more information about the Joint Commission lab or hospitalwide surveys, contact Spicer at (617) 726-5109 or mspicer@partners.org.