What if there was a quick, easy, no-cost way to converse and interact with laboratory professionals around the globe? Would you join in? While millions of people have found that MySpace and LinkedIn can help them find long lost friends and network, there hasn’t really been a place to discuss quality improvement issues at The Joint Commission ― until now.
The Joint Commission-sponsored WikiHealthCare™ is an interactive site where users can post questions and comments about standards, requirements and other quality improvement topics. It’s worthwhile to sign up for this online community and share your views. For details, see the article below.
Meanwhile, we will continue to use online field reviews to gather feedback. Of particular importance this year will be the field reviews resulting from the Standards Improvement Initiative (SII). This initiative is designed to:
- Clarify standards language
- Ensure that standards are program-specific
- Delete redundant or non-essential standards
- Consolidate similar standards
Your input will be crucial to making this initiative a success. You can tell us what you think by completing the surveys as they become available online. See the article for more information.
Margaret Peck
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You might read blogs, check out facts on Wikipedia and maybe even have a profile on a networking site such as LinkedIn or MySpace. These are web-based communities or hosted services that aim to facilitate creativity, collaboration and sharing among users. Now, there’s an interactive forum designed specifically for health care professionals called, WikiHealthCare™.
WikiHealthCare is an interactive site where users can exchange information related to quality improvement and other topics. Since mid-2007, it has been visited by more than 23,000 unique users in 110 countries. Currently, there are nearly 4,000 registered participants.
“Laboratorians are invited to help build WikiHealthCare into their own professional network. As the site evolves, participants will create a community that allows them to converse with the nation’s leading researchers and thousands of health care professionals who are interested in improving health care quality,” says Scott Williams, associate director, Division of Quality Measurement & Research. “The content, critiques, edits and comments are all contributions from the community. The Joint Commission sponsors the site, but does not own the content.
“If you’re new to the site you may want to watch a demonstration and read, What is WikiHealthCare? or How do I use WikiHealthCare?” explains Williams. “You can even watch a demonstration that explains how the site works. After that, nose around the topic areas. Feel free to add text, edit existing text and make comments.”
The site is set up in two sections ― Quality Improvement and Standards Development & Research. “Within the Quality Improvement forum, participants may review or contribute to existing quality improvement topics, or they can suggest new ones. In the Standards Development & Research forum, participants have the opportunity to explore emerging issues in the field and to provide input that may be used to construct new accreditation requirements or standards,” says Williams.
It’s important to note that all users participate as individuals, not as representatives of their organization. Participation has NO impact upon an organization's accreditation status.
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National Patient Safety Goal 2C and proficiency testing standards QC.1.20 and QC.1.30 were the most problematic requirements for labs in 2007. Each year, The Joint Commission collects data on organization compliance with its standards, National Patient Safety Goals, and other requirements to identify trends and focus education activities.
“Labs can use this information to benchmark performance against all Joint Commission accredited labs and to determine if their processes meet the requirements,” says Margaret Peck, executive director, Laboratory Accreditation Program.
The box below lists the areas that were most frequently identified as “not compliant” for clinical laboratories. The percentage of organizations that received Requirements for Improvement is provided in parentheses after the requirement number. For detailed information and recommendations on how to improve your lab’s performance, see the FAQs , or contact the Standards Interpretation Group through its online question form.
Goal 2 Requirement 2C (21%) Measure, assess, and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
QC.1.20 (20%) Proficiency testing services used for specialty and subspecialty equal or exceed applicable laws and regulations with respect to variety and frequency of testing and satisfactory performance criteria.
QC.1.30 (18%) The laboratory maintains a cumulative record of participation in a proficiency testing program.
QC.5.300 (12%) The laboratory uses standardized procedures to acquire, receive, store, and issue tissues.
EC.6.20 (11%) Laboratory equipment is maintained, tested, and inspected.
LD.2.60 (10%) The directorship of the laboratory is effective.
WT.1.60 (9%) Quality control and test result records are maintained.
QC.5.310 (7%) The laboratory’s record keeping permits bi-directional traceability of all tissues.
QC.5.80 (6%) The laboratory uses written policies, procedures, and processes for administering blood and blood components and using infusion devices and ancillary equipment.
Goal 1, Requirement 1A (6%) Use at least two patient identifiers when providing care, treatment, or services.
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As part of The Joint Commission’s Standards Improvement Initiative (SII), the Board of Commissioners approved new, improved and simplified scoring and decision processes, effective January 1, 2009, for all accreditation and certification programs. The current accreditation decision process is primarily based on the volume of survey findings in relation to pre-established thresholds. The new processes:
- Are based on the “criticality” of survey findings. This means that accreditation decisions and the timing of follow-up requirements are judged in relation to the immediacy of the threat to health care quality and patient safety as the result of non-compliance with Joint Commission requirements.
- Reflect an organization’s performance respecting compliance with Joint Commission standards and elements of performance.
Please note that the proposed changes to the scoring and decision processes are still under review by The Joint Commission. An overview of SII published in Update 1 is also available on The Joint Commission website. This overview includes more information about scoring and accreditation decisions. Final changes to the scoring and decision processes will be published by July 1, 2008 on The Joint Commission website.
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Cherie Ulaskas, MT (ASCP), MA, associate director, Standards Interpretation Group, answers questions that she has fielded recently from accredited laboratories.
Q: We have new PT/INR instruments that fall into the waived category. Do we have to perform proficiency testing since this is a regulated analtye?
A: No, The Joint Commission does not require proficiency testing for waived tests.
However, some organizations conduct proficiency testing as part of their competency assessment.
Make sure that your new instrument is a waived instrument. You can do this by contacting the manufacturer; checking the Clinical Laboratory Improvement Amendments website; or checking the Food and Drug administration website.
Q: Who is responsible for waived testing, the laboratory or nursing staff?
A: Your organization must determine which department has oversight of waived testing, who is responsible and how it fits into the overall quality improvement activities of the organization. It’s important to remember that the standards are applied to your organization as a whole and not just to laboratory or nursing.
This is specified in Standard WT.1.20 which states:
The director named on the CLIA certificate identifies the staff responsible for performing and supervising waived testing.
If you have a question you’d like to see answered in the Accreditation Workshop, e-mail it to Pamela Schumacher, editor, pschumacher@jointcommission.org.
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Audio conference
The Joint Commission Application Process―How to Get Started
April 9
Participants work through a sample application in this audio conference held from 11:30 a.m. to 1:00 p.m., CT. The fee is $249 per connection. Organizations can sign up for one telephone connection with multiple attendees participating in one conference room.
Education
Laboratories: A Primer for Beginners
October 22, Oakbrook Terrace, Ill., $100
Receive fundamental information about the standards and the accreditation process at this seminar, which provides the foundation for the Laboratories: Accreditation Essentials program that follows.
Laboratories: Accreditation Essentials
October 23, Oakbrook Terrace, Ill., $450
This interactive, solution-based seminar provides practical strategies and implementation tips. Topics include standards and elements of performance, the National Patient Safety Goals, and all relevant updates.
Publications
2008 CAMLAB Subscription Update Service
Order code: CLSM08S, $200
Accreditation Process Guide for Laboratories
A comprehensive, user-friendly source guide designed to help laboratories understand the Joint Commission accreditation process.
Order code: APGL05SJ, $80
From Practice to Paper: Documentation for Laboratories
Learn how to make sure your documents capture the information your laboratory needs to comply with the standards and improve the quality of its services.
Order code: SDFL01SJ, $55
For registration information or to order, call Joint Commission Resources, Inc., toll-free at (877) 223-6866, 8 a.m. to 8 p.m. C.T., or go to http://store.jcrinc.com/.
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• Laboratory Accreditation (630) 792-5866
• Standards Interpretation Group (630) 792-5900
• Laboratory Account Representative (630) 792-3007
• Customer Service (630) 792-5800
• Pricing Unit (630) 792-5115
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