The Joint Commission strives to help health care organizations help patients. The goal of the Standards Improvement Initiative is to ensure the relevancy of Joint Commission standards in a changing health care environment. In line with our mission, SII will help labs improve the quality and safety of their services, make the standards more laboratory-specific and result in improved patient safety.
We’ve already made progress. Initial changes for laboratories as a result of SII are:
- Changes in the scoring and decision process effective January 1, 2009 for all accreditation and certification programs.
- Color-coded tabs added to 2009 print manuals to distinguish standards and requirements from accreditation policies and procedures.
- A complimentary, single-user license, electronic E-dition of the laboratory accreditation manual to be distributed in late 2008.
To get a peek at some of the changes coming in January 2009, go to the website (or look at the second edition of the Update that will be mailed to every accredited lab in October. In this edition, you can review the new format for tagging critical, direct impact and situational requirements in the Leadership Chapter, the new Accreditation Participation Requirements, and the 2009 National Patient Safety Goals.
In 2010, laboratories will see further improvements including:
- The ability to sort relevant standards and elements of performance applicable to the services/programs provided by the organization.
- Links from certain elements of performance to associated requirements in other chapters.
- Standards and EPs related to a focused area of improvement placed in relevant chapters.
We’re still in the process of revising the standards and we want to hear from you. To participate in the field reviews for the Information Management and Performance Improvement chapters, click here. Meanwhile, if you have any questions about SII, I’d be happy to answer them. Contact me at mpeck@jointcommission.org or call (630) 792-5287.
Margaret Peck, MS, MT (ASCP)
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As part of The Joint Commission’s Standards Improvement Initiative (SII), the Periodic Performance Review process and availability of the on-line PPR will be affected. The PPR will be off-line from December 1, 2008 until January 1, 2009. During that time, the new standards and scoring methodology will be loaded onto the site. Therefore, the due dates for completing the PPR are being changed as follows:
- Organizations with PPR due dates from October 1, 2008 through December 31, 2008 are not required to submit a 2008 PPR.
- Organizations that wish to document Plans of Action for requirements for improvement (Full PPR or post-survey Option 2 PPR) must submit the 2008 PPR by Sunday, November 30, 2008 at 11:59 p.m. Central Time.
When the PPR is re-activated on January 1, 2009, labs will need to re-evaluate standards labeled as requiring an update. The majority of the standards will be automatically populated as the numbers have not changed for 2009. In addition:
- PPR Option 2 and 3 surveys will not be scheduled in November or December 2008. PPR Option 2 or 3 surveys scheduled for 2009 will be conducted using the 2009 standards.
- For organizations with PPR due dates in January, February or March 2009, the “Begin Submission” link will not be activated in the Open PPR during the fourth quarter of 2008; it will become available on January 1, 2009.
- If your PPR is due in January 2009, your due date will be extended by 90 days. For example, if your PPR is due January 15, 2009, your extended due date will be April 15.
- If your PPR is due in February or March 2009, your due date will be extended by 60 days. For example, if your PPR is due February 15, 2009, your extended due date is April 15; if your PPR is due March 15, 2009, your extended due date is May 15
For more information about SII, click here.
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The Joint Commission has established a Blood Management Performance Measures Project to identify, develop and test a set of standardized measures to help assess blood management in the hospital setting. A field review to gather comments on proposed performance measures has been conducted and the results are being analyzed, more information will be available in the next issue of Lab Focus. To read more, click here.
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Megan Sawchuk, MT (ASCP)
Associate director, Standards Interpretation Group
Q. Our hospital information system captures data from our laboratory system and provides the results in several other hard copy and electronic formats accessed by our physicians, such as the physician portal, flash reports, remote web access, etc. Do all these different reports need to conform to the standards surveyed during the biennial laboratory survey?
A. Yes. Laboratory reports are specifically formatted to improve physician readability and to reduce interpretation error. As information technology advances and allows for more convenience and customization, hospital and laboratory leaders must ensure that the laboratory report read by the end user meets Joint Commission standards and the federal Clinical Laboratory Improvement Amendment regulations.
The requirements for organizations to integrate the needs of the laboratory into its information management plan are listed in the hospital accreditation standards IM.1.10, EP 1 (second bullet) and LD.2.20, EP 5. The first standard requires the hospital to plan and design information management processes to meet internal and external needs, which includes those identified for individual departments and in accordance with accrediting and regulatory bodies. The second requires the hospital to have effective leadership that ensures coordination of its services among departments.
Laboratory representation on medical records development and implementation teams is essential to ensuring that hospital decision makers and software vendors are aware of the specific accreditation and regulatory requirements for laboratory reporting formats. For laboratory testing designated as non-waived, this includes (but is not limited to) requirements for the following: name and address of the laboratory, patient name, patient ID number, specimen source, specimen date and time, reference ranges, units of measure, date and time of reporting, the condition of unsatisfactory specimens, as well as ensuring that reference laboratory results are not revised. Note: For lab testing designated as waived, the reporting requirements may be less stringent for some of these elements. Please refer to the respective standards for further information.
If you have a question you’d like to see answered in Accreditation Workshop, send it to Pamela Schumacher, editor, Lab Focus, at pschumacher@jointcommission.org.
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The 2009 National Patient Safety Goals have been updated with improvements emanating from the Standards Improvement Initiative, including a new numbering system and minor language changes for consistency. The new numbering format was designed to enable sorting electronically (for the new E-ditions of the manuals) and to accommodate the addition of new requirements. Under the new numbering system, each requirement is assigned a six-digit number that designates its place in the chapter. To see the full text, click here.
The Joint Commission’s Ernest Amory Codman Award program is being refreshed. During the next year, The Joint Commission will take a fresh look at the application and evaluation processes as well as the program requirements. In existence for 12 years, the Codman Award program has provided an opportunity for The Joint Commission to recognize organizations and individuals doing excellent work in performance measurement. The winners of the 2008 Codman Award will be recognized in November 2008 at The Joint Commission and Joint Commission Resources Annual Conference and the 2010 Codman Award application process will begin in the fall of 2009.
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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 from the JCR website.
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
Coming Soon! 2009 Laboratory Accreditation Standards
This handy spiral-bound reference book contains standards, rationales, elements of performance, National Patient Safety Goals, and accreditation policies and procedures.
Order code: LSM09, $110
Coming Soon! 2009 Accreditation Process Guide for Laboratories
A comprehensive, user-friendly guide designed to help understand The Joint Commission accreditation process.
Order code: APGL09, $119
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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