Friday, May 3, 2013

Window opens for 2013 Joint Commission hospital lab-focused survey

THE WINDOW FOR a Joint Commission survey with a lab focus is now open and can occur at any time. The Joint Commission will send three surveyors for a five-day review of all MGH laboratory services. Surveyors will visit the MGH’s main campus, health centers and practices, and perform tracers in any location involved in laboratory service activities and transplant safety. The scope of the survey could include physicians, nurses, medical assistants, point-of-care testing personnel and laboratory employees. 

Surveyors will cover all the steps in performing laboratory tests and blood transfusions: documentation and practice for ordering tests, collecting specimens, managing results, performing point-of-care tests and fully documenting all blood transfusions. Common point-of-care tests include fecal occult blood, fingerstick glucose, urine dipstick, urine HCG, rapid strep and provider performed microscopy – including both wet preps and urine sediment. MGH laboratories have designated patient identification and specimen collection quality and safety as priorities for 2013.

To help MGH services have a successful survey staff should:

1. Be prepared to describe the process for:

•  Drawing blood from a patient;

•  Verifying and completing orders for
laboratory testing;

•  Managing critical values;

•  Ensuring proper patient identification and specimen collection; and

•  Performing point-of-care tests.

2. Ensure that two patient identifiers are always verified and used:

•  In the presence of the patient;

•  On all specimen containers and requisitions; and

•  On all point-of-care devices and slides, even if the test is performed in the exam room with the patient.

3. Ensure that all orders and results are documented in the patient electronic record:

•  Document and read back the communication of all critical values to the responding clinician.

•  Document orders/protocols and results for point-of-care tests. Verbal orders and results are not sufficient.

4. Perform mini-tracers:

•  Perform a mini-tracer of a patient test and check for: order, result, competency assessment, quality control and temperature record. Please note that a physician performing point-of-care tests must have documented competency assessments.

As with all survey processes, this is an opportunity for the MGH to demonstrate the excellent care staff provides to patients every day. For more information about the survey or about specific locations contact Cynthia Mansfield at or 617-726-8172.


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