Your input on Joint Commission field reviews is crucial in giving the laboratory profession a voice in what the future standards and accreditation process will look like. If you’re wondering what exactly a “field review” is, they are simply online surveys asking your opinion about proposed revisions to the standards and accreditation process. I hope you make it a habit to respond, especially now that we’ve added a new list-serve notification option. All you have to do is sign up for the Standards Field Review list-serve. It’s easy, quick and guarantees you’ll never miss another field review.
I’m pleased that we have heard from many of you during the recent field review for the Standards Improvement Initiative. The Joint Commission is already into Phase 2 of this comprehensive project and continues to move forward rapidly. We are revising and reorganizing the accreditation manuals, tossing out redundant standards and consolidating similar standards.
You’ll get a chance to see some of these improvements in the revised scoring and decision process that will go into effect in January 2009. It’s an exciting time and I’m encouraged by the work accomplished so far. I will continue to keep you posted on our progress. Meanwhile, contact me at mpeck@jointcommission.org if you have any questions or concerns regarding SII or the laboratory accreditation program.
Margaret Peck, MS, MT (ASCP)
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The Joint Commission’s Standards Improvement Initiative has entered into Phase 2 with the launching of surveys to assess satisfaction with current requirements in the Laboratory, Behavioral Health Care, and Long Term Care Accreditation Programs. SII was inaugurated in August 2006 for the Phase 1 programs as part of The Joint Commission’s continuous effort to improve the standards.
“SII focuses on enhancing the clarity and relevance of current standards and elements of performance. No new requirements have been added,” says Carol Gilhooley, director, Standards and Survey Methods. “We are refining the scoring and decision processes to be more objective, enhancing the manuals for easier use, implementing simple, direct language, and avoiding hard-to-measure words, like ‘as needed,’ ‘appropriate,’ and ‘timely.’ The breadth of the initiative made it necessary to conduct these activities in phases."
Phase 2 timeline:
- Field review of accreditation manual chapters for laboratories, behavioral health care and long term care programs
- Phase 2 unique requirements reviewed during second half of 2008 and the first half of 2009
- New scoring and decision rules effective January 2009
- Implementation of revised standards and elements of performance planned for January 2010
For more information about SII, see the FAQs.
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There are no major additions to the 2009 Laboratory National Patient Safety Goals. However, labs should be aware of a new NPSG on eliminating transfusion errors that will apply to hospitals, critical access hospitals, ambulatory care programs and office-based surgery accreditation programs, says Margaret Peck, executive director, Laboratory Accreditation Program. The full text of the NPSG and elements of performance follow:
NPSG.01.03.01
Eliminate transfusion errors related to patient misidentification.
Elements of performance
- Before initiating a blood or blood component transfusion, the patient is objectively matched to the blood or blood component during a two-person bedside or chair-side verification process. At least two unique identifiers are used in the process, and it is conducted after the blood or blood component that matches the order has been issued or dispensed. Note: If two individuals are not available, an automated identification technology (for example, bar coding) may be used in place of one of the individuals.
- When using a two-person bedside or chair-side verification process, one individual conducting the identification verification must be the qualified transfusionist who will administer the blood or blood component to the patient.
- When using a two-person bedside or chair-side verification process, the second individual conducting the identification verification must be qualified to participate in the process.
For more information about the NPSGs, visit the website.
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Megan Sawchuk, MT (ASCP)
Associate director, Standards Interpretation Group
Q. How does the labeling of specimens, as required by National Patient Safety Goal 1A apply to fine needle aspirates collected in the radiology department and given to the laboratory?
A. Requirement 1A states: Use at least two patient identifiers when providing laboratory services. This includes specimens retrieved from a procedure in which the Universal Protocol was used to identify the patient. If laboratory staff picks up the specimen after the procedure started, it is not an expectation of the Universal Protocol for that person to participate in the patient identification or “time-out.” Accordingly, the specimen should be provided to the laboratorian labeled with two patient identifiers by a participant who was present during identification of the patient.
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The 2009 accreditation program manuals, including the laboratory manual, will be available electronically as “E-ditions” beginning in November 2008. Along with the customary free print copy of the manual, organizations will receive a free E-dition (i.e., single-user license). The E-ditions will be accessed on the Internet via a log-in and password. Features will include key word search capability across one or more manuals, access to every standard in three “clicks,” and the new scoring categories. (Please note that for the laboratory program, some features related to ongoing SII improvements will be available in the 2010 E-ditions.) More information, including how organizations will receive the E-ditions, will be available in September.
Klaus Nether, MT (ASCP), SV, associate director, Division of Standards and Survey Management, has been invited to serve as a member of the Advisory Committee on Blood Safety and Availability, a federal advisory committee to the Department of Health and Human Services. The committee includes representatives of the blood and blood products industry and professional organizations. As the volume of transplants increases, this will be a rapidly emerging area for quality and safety focus. Klaus’ involvement with this group will ensure that The Joint Commission stays involved and is proactive in developing new standards.
A new study aims to find new ways to help consumers better understand health care quality data and how to use that information to make informed health care decisions. This 18-month study, funded by a grant from the Robert Wood Johnson Foundation, is designed to identify principles and guidelines for the presentation of electronic hospital quality information and explore ways in which consumer understanding of the information facilitates health care decisions. A panel of experts in the areas of consumer use of quality information, adult learning and health media will provide guidance throughout the study.
Two new RSS (Rich Site Summary) feeds are now available on The Joint Commission website. The new feeds allow users to get Joint Commission podcasts and “What’s New on The Joint Commission Website.” Users will need to download a new reader and pod catcher for the new feeds. To download the feeds or get more information, visit the website.
This free Speak Up™ brochure offers patients questions and answers that will help them better understand the care they receive. See the brochure.
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Free brochure lists lab resources
Joint Commission Resources is offering a free brochure, “Choose the right path to improve your knowledge and skills,” to help laboratory managers decide which Joint Commission publications, seminars and conferences are right for their organization. It’s available for free - click here.
Audio conference
National Patient Safety Goals Series: Laboratories
July 28
Learn all about the National Patient Safety Goals in this 90-minute audio conference which includes a formal presentation followed by a Q&A. The session will be held from 11:30 a.m. to 1 p.m., sign up for one telephone connection with multiple attendees participating in one conference room. The audio CD, complete with handouts, is available for purchase.
Education
Laboratories: A Primer for Beginners
October 22, Oakbrook Terrace, Ill.
Receive fundamental information about the standards and the accreditation process, which provides the foundation for the Laboratories: Accreditation Essentials program that follows.
Laboratories: Accreditation Essentials
October 23, Oakbrook Terrace, Ill.
Provides practical strategies and implementation tips for standards and elements of performance, the National Patient Safety Goals, and relevant updates.
Publications
2008 CAMLAB Subscription Update
Keeps your organization current with the latest accreditation information. Update 1 (March) focuses on changes made as a result of the Standards Improvement Initiative that are effective January 1, 2009.
Update 1 is available for free, click here.
Accreditation Process Guide for Laboratories
A comprehensive, user-friendly 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) 792-5287
• 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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