Friday, March 11, 2011

Excellence Every Day

Joint Commission lab survey window opens

MATCH IT: The Joint Commission will survey all areas of the MGH associated with laboratory service activities.

THROUGHOUT THE MGH, “Excellence Every Day” is the goal for each and every hospital employee, whether providing hands-on clinical care to critically ill patients or ensuring the campus’s public restroom floors are clear so that no one slips or falls. The daily emphasis on excellence is always of utmost importance. And sometime between Feb. 28 through Aug. 28, the hospital’s efforts to reach excellence every day will be assessed by Joint Commission laboratory surveyors.

The Joint Commission accredits and provides certification to more than 18,000 U.S. health care organizations and programs. Accreditation is a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. During the lab survey period, the Joint Commission will send three surveyors for a five-day review of the hospital’s laboratory services.

MGH practices on the main campus and off-site, including the MGH health centers, will be surveyed, as well as all on-campus laboratories. The assessment will include inspections of activities and areas associated with laboratory service activities – such as test ordering, specimen collection, test result management and point-of-care testing. Some common point-of-care tests are finger-stick glucose, urine dipstick and provider-performed microscopy.

“As with all survey processes, this is an opportunity for the MGH to demonstrate the excellent care we provide to our patients every day,” says Donna MacMillan, director of Operations for the MGH Pathology Service. MacMillan offers the following ways MGHers can help to ensure the hospital has a successful inspection:

  1. Ensure that two patient identifiers are always verified and used:
    • in the presence of the patient and
    • on all point-of-care test devices and slides even if the test is performed in the exam room with the patient.
  2. Ensure that all orders and results are documented in the patient’s electronic record. Communication of critical values should be documented in the chart and read back. Point-of-care verbal orders and results are not sufficient.
  3. Perform a mini-tracer of a patient test and check for order, result, competency assessment, quality control and temperature record. Physicians performing point-of-care tests must have documented competency assessment.

 “We’d like to remind the MGH community that this Joint Commission laboratory survey should be treated as a hospitalwide survey with a lab focus,” adds John Belknap, director of MGH Compliance. “All areas surveyors come upon – public areas and nonlab areas – can and will be assessed for compliance.”

For more information about the survey, contact MacMillan at or 617-726-8887 or Cynthia Mansfield, associate director of Compliance and Operations for Clinical Pathology, at or 617-726-8172.

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