Q. Some of our lab reports do not include the date and time of reporting, as required by DC.02.03.01 EP 10. We are working with our software vendor to remedy the situation. If we receive a finding on survey and are unable to get the problem fixed before our evidence of standards compliance (ESC) or measure of success (MOS) due dates, will we fail the ESC or MOS?
A. No, neither the ESC nor the MOS will be failed. The long term objective should be to ensure all versions of the laboratory report (hard copy or electronic) contain all the required fields. As it may be a challenge to comply with the specific requirement to print the date and time of reporting on the laboratory report, we have two approaches to support realistic options for laboratories.
First, we will accept the standard as compliant if the date and time of reporting is present on any single version of the report in the patient’s permanent medical record (hardcopy or electronic). Second, when the corrective action involves a software solution, we will accept an ESC as compliant if the laboratory has an implementation plan, provides a reasonable timeline for implementing the plan (depending on the cost, anticipated software upgrades, etc.), and the date and time of reporting is electronically retrievable in the interim, for instance through your Laboratory Information System. This is acceptable even if implementation exceeds the usual 45-to-60 day timeline for an ESC. If the plan cannot be fully implemented before the MOS is due four to six months later, we will advise your account executive to accept the MOS in anticipation that the corrective action will be implemented as set out in the timeline of the approved ESC.
On a related topic, hospital leaders may not be aware of the specific requirements for laboratory reports when implementing an electronic medical record system. Information on this topic is available on The Joint Commission Web site in the hospital FAQ titled “Laboratory Report Requirements in the Medical Record.