I recently reviewed some of the applications submitted for the Ernest Amory Codman Awards ― The Joint Commission award that recognizes excellence in performance measurement. I was impressed by the dedication and commitment to quality improvement shown in the applications, but it got me to thinking.
The last lab to win a Codman Award was the Laboratory at Warm Springs+Baptist Rehabilitation Hospital in 1998. I believe there are many more labs deserving recognition as a significant partner on the health care team.
Ask yourself: Has your lab achieved significant improvements in care as evidenced by process or outcomes measures? Is your lab’s performance improvement work unique? Are you a pioneer in a new area of quality improvement? Have others commented that one of your performance improvement initiatives could lead to a breakthrough in clinical treatment? Have your efforts been recognized by others? Would you like to be recognized on Quality Check? If the answer to any of these questions is yes, your organization is a prime candidate for the prestigious Codman Award.
Information about past winners, and tips and advice on applying are available online. The 2008 application will be available in mid-November. If you have questions, contact Teena Wilson at twilson@jointcommission.org or (630) 792-5562.
Margaret Peck, MS, MT (ASCP)
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If you want to know what the next “new thing” will be in patient safety and quality improvement, participate in The Joint Commission’s field reviews. Overall, the Joint Commission conducts about 10 field reviews annually through online surveys. Input from these reviews helps to identify best practices, anticipate concerns, and determine if changes are “the right thing to do,” says Joyce Marshall, senior research associate.
“People have misconceptions about the field reviews,” Marshall says (see “Field review mythbusters”). “However, filling out the online survey is a good way to let The Joint Commission know how revisions are going to affect your facility. It’s important to allow enough time to thoroughly read what the Joint Commission is proposing. Generally it only takes 15 to 20 minutes to complete a survey.”
Your responses count
Any number of people from an organization can respond to the field review and, even if you think a field review doesn’t apply to your organization, you can still respond.
“We need to hear from laboratories so that the standards expectations and language appropriately reflect their needs,” Marshall says. “We read and analyze every response. We use the data to confirm that we are on the right track or to redirect the proposed requirements.”
In addition to the field review, The Joint Commission gathers feedback from:
- Conference calls and expert panels
- Advisory groups
- Surveyors
- Current research
“It can take about six months from the time we close a field review to publication in an accreditation manual,” Marshall says. “If you want to check the status of a particular set of standards or revisions, check page 2 of Perspectives. The ‘In Sight’ section will tell you if revisions are in development, in committee or board review, being field reviewed, or if they’ve been approved.”
View the most current field reviews.
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Field review mythbusters |
- “My response will be traced back to my organization.”
BUSTED! All responses are confidential.
- “My response will affect my accreditation survey.”
BUSTED! The responses are not tracked to an organization.
- “My opinion doesn’t matter.”
BUSTED! Your opinion always matters, but we gather a lot of opinions from a wide range of professionals.
- “The requirements are not applicable to my organization.”
BUSTED! You have to tell us that a requirement is not applicable to your setting or that the language is not appropriate. This will help us when we’re writing the requirements for your field. |
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Mark R. Chassin, M.D., M.P.P., M.P.H., has been appointed to lead The Joint Commission as its next president, effective January 1, 2008.
Chassin is the Edmond A. Guggenheim professor of health policy and chairman of the Department of Health Policy at Mount Sinai School of Medicine, New York, and executive vice president for Excellence in Patient Care at The Mount Sinai Medical Center. Prior to joining Mount Sinai, he served as commissioner of the New York State Department of Health. He is a board-certified internist and practiced emergency medicine for 12 years.
Dennis S. O’Leary, M.D., who has led The Joint Commission for the past 21 years, will become President Emeritus on January 1, 2008.
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Q. For National Patient Safety Goal 2C, what is meant by the term “critical test results” and what are the timeframes we should be measuring?
A. NPSG 2C says: Measure and 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.
There has been confusion about whether this requirement refers to a test result that is critical or the result of a critical test. This NPSG requirement addresses both. To comply, an organization needs to make a distinction between:
Critical tests: Tests that require rapid communication of the results, even if the results are normal, e.g., cardiac markers collected from a patient in the emergency department. The time interval to be measured is from when the test is ordered to the reporting of the result.
This goal applies to all diagnostic services within a hospital, so it is appropriate that laboratory leaders specify how the term “critical test” is used. One approach is to define critical tests as all exams ordered “stat,” since these tests must be conducted immediately and results reported immediately. Laboratories are typically collecting stat turn-around-time data, which would satisfy the intra-laboratory measurement. Periodic random sampling of the ordering-to-collecting timeframe would complete the analysis.
Critical results: Results (even if from routine tests), which require rapid communication of the results. For example, “panic values” or “red-line values” which are critically abnormal results that require immediate action because the patient is in imminent danger. Because you can’t know that the result is critical until the test is done, the ordering-to-testing timeframe is not relevant. The time interval to be measured is from the identification of the critical result to the reporting of that result.
Note: There is no requirement to report all “critical tests” verbally. The laboratory's routine reporting process is sufficient for compliance. Acknowledgment of the results, usually verbal, is only necessary for “critical results” to ensure that prompt action is taken.
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We want your feedback about Lab Focus and what we can do to improve its value and usefulness. Take the survey.
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There are no major additions to the 2008 Laboratory National Patient Safety Goals. However, the Requirement related to hand hygiene has been modified to allow for the use of the World Health Organization (WHO) Hand Hygiene Guidelines as an alternative to the Centers for Disease Control and Prevention (CDC) guidelines. See the full text.
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Consumers can now search for a laboratory on Quality Check® by the types of services provided in addition to the type of facility. For labs, this includes:
- General laboratory tests
- Blood donor center
- Genetic testing
- In-vitro fertilization
- Toxicology testing
In addition, beginning October 1, Quality Check will include health care organizations that are not accredited by The Joint Commission. The addition of non-Joint Commission accredited organizations provides health care consumers with more information and highlights the value of accreditation.
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The Leadership Chapter has been revised for all accreditation programs as part of The Joint Commission’s regular standards renewal process. The revisions will go into effect January 1, 2009.
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Education
Accreditation Essentials: Laboratories
This one-day, advanced program focuses on the accreditation process and standards, CLIA regulations, revisions to waived testing standards, new infection control standards, compliance strategies and National Patient Safety Goals.
Nov. 9, Oakbrook Terrace, Ill.
E-tools
Accreditation Manager Plus: An Interactive Toolkit for Continuous Compliance™
This electronic tool arms your organization with everything it needs — in one electronic package — to maintain continuous compliance and prepare for the Periodic Performance Review. Choose from individual PC, network, web-based intranet, or web-based extranet versions.
Publications
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 are capturing the information your laboratory needs to comply with the standards and improve the quality of 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 www.jcrinc.com/Infomart.htm.
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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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