(Sharon) Hello, everyone, and welcome to today's webinar:
Peer perspectives: leverage the synergies
of using The Joint Commission accreditation
for your laboratory and hospital.
My name is Sharon, and I will be your moderator for today's webinar.
Next slide, please.
Welcome, everyone.
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Next slide, please.
I'm Sharon Hibbe, Associate Director for the laboratory accreditation program.
I'm delighted to have my special guest today,
Mrs. Lynnette Chakkaphak,
Regional laboratory director for Ascension St. Vincent's Jacksonville, Florida.
Mrs. Chakkaphak received her Bachelor's degree
in medical technology from the University of Massachusetts.
Amherst Massachusetts,
and completed her training at Baystate Medical Center,
Springfield Massachusetts.
After working for many years in the field of Immunology and Microbiology,
she continued her education at the University of South Florida
where she was awarded a Graduate Council fellowship
and earned her Master's degree in Microbiology.
Mrs. Chakkaphak's experience includes 40 years
in medical laboratory management and education.
Currently, she is with Ascension St. Vincent's in Jacksonville, Florida,
as a Regional Laboratory Director,
In addition to overseeing laboratory services
for four acute care hospitals
and two free-standing emergency rooms,
Mrs. Chakkaphak directs the operations of a large outreach laboratory business.
Recognized in 2020 with the ASCP President's Award,
Mrs. Chakkaphak has been involved in the ASCP volunteer activities since 1999
and has served in a variety of capabilities,
including as Executive Committee Member
and Secretary of ASCP, Member of the Board of Directors,
Chair of the commission on membership,
Chair of the Council of laboratory professionals,
Chair of ASCP's scholarship committee
and member of Choosing Wisely Test Utilization Committee.
It's with my great pleasure to now turn it over to Mrs. Chakkaphak.
Next slide, please.
(typing)
Lynnette, I think you're on mute, you can unmute your phone.
Go ahead, Lynette.
(Lynnette) Can you hear me now?
Hello, can you hear me now?
(Sharon) Yes, we do. Go ahead.
(Lynnette) Okay, awesome. Thank you and I apologize.
Maybe my husband's finger was on that mute button, I don't know.
Sometimes, he thinks I talk too much.
Sorry for the delay, and let me just double-check, Sharon,
you guys can hear me fine?
(Sharon) Yes, thank you.
(Lynnette) Okay.
Today I planned to tell the story of my experience
and my health system's experience with The Joint Commission survey process.
And I'm going to get us started though
by going over a few objectives that I've written to guide that story.
I'm going to start by describing our Joint Commission experience
from the perspective of a lab that has never used Joint Commission before.
Then, I'm going to discuss the use of the Tracer methodology
as the key driver of that survey process.
I hope to highlight the synergies of utilizing a single accrediting agency
for both our hospital and our laboratory,
and how that was an advantage to us,
and just consider the overall positive impact
that using Joint Commission for our accreditation
has made on patient care, here, in our organization.
If you could advance to the next slide, you'll see that I pose the question,
"Why did we even consider a change to Joint Commission lab accreditation?"
First of all, I should explain that in my 45-year career in the laboratory,
I've never worked in a laboratory that was Joint Commission accredited.
And so, just like many of you, when something is brand new to me,
I'm a little bit uncertain about it.
I have a wealth of experience on how to prepare myself
and what was going to happen with my previous accrediting agency.
So when Ascension, which I'll explain, if you've not heard of Ascension,
Ascension is 160 hospital or so Catholic health care organization
across the United States,
certainly the largest Catholic health care organization,
and one of the largest healthcare organizations in the United States,
both Catholic and non-catholic.
It was discussed among the laboratory directors,
we meet as a group,
that we should probably consider uniting ourselves
across all of these hospitals into one accrediting agency.
There were some locations across the United States with Ascension
that were already Joint Commission accredited
and then there were others like us that used a different accrediting agency.
So we agreed that we would come up with a group,
a subset of our directors
that represented some that already use Joint Commission,
and those that did not,
to think of all the pros and cons that would meet separately,
and bring back to the larger group,
what our thoughts were on,
coalescing around one accrediting organization.
Fortunately, I got to be a part of that team,
and as we thought about that, we thought about a lot of categories.
And I've just honed in on a few of these here.
And that was, as we talked about,
what were the pros and cons of the different accrediting agencies.
We thought about problems that had arisen during our...
the accreditation process.
Everybody had their story to tell about some problem.
Again, these are lab directors and many of you are managers.
And laboratory directors, I'm sure, yourself that are on the line
and so you can probably think of something that didn't go well
during your accreditation process.
(electronic beep)
For myself, I was able to tell the story of a surveyor or inspector
that arrived in our laboratory and announced to my team,
the first thing they said to our team was that they've never been to a lab,
that they weren't able to find at least 20 deficiencies
and that they plan to find at least 20 deficiencies before they left.
If that was in your opening discussion with your surveyor/inspector,
I don't think you'd probably feel very good
about the way the inspection
or the or the value of that inspection or survey process
was going to be to your laboratory.
And so, again, I share that story,
but that also leads into the whole idea of the usefulness of the findings
in that particular story that I was just alluding to.
That inspector kept us there until 9 o'clock at night
because they were, I think, frustrated to not find more problems or half.
So, they stayed and stayed.
They even came in early the next morning
and kept us waiting throughout the day
for the the proper process to happen.
And what ultimately happened is all of the...
I think all of the deficiencies that that inspector found were overturned
by the accrediting organization.
We provided documentation, which was in place at that time
of the surveyor/inspector coming on board.
And so, that accreditation process is just one example of how useless
the inspection process was to our laboratory.
It was not helpful to our organization in any way
and it represented largely just the opinions of the individual
that came to inspect us.
Again, I'm talking about that process
of why did we choose to switch to Joint Commission.
I was not the only lab director that had those kinds of concerns to share.
The purpose of accreditation is of course to hold our labs to a high standard
to help assure great patient care
and the highest quality possible of our laboratory,
in our laboratory services.
And to have spent all of our energy preparing our laboratory,
only to have that process be almost sidetracked, if you will,
through this very negative experience was not useful or helpful in any way
to the quality within our lab.
Another aspect that we talked about is we have now four hospitals here,
and the need to go out and therefore do an inspection,
somebody comes and inspected or surveys us,
we must reciprocate and go, of course, inspect elsewhere.
And it was taking our team a great deal of time to do that.
Between our pathologists as well as our laboratory teams,
we run our health system, system lab.
That means I have a system manager over blood bank,
a system manager over microbiology, for example.
And these individuals would have to go out on all these inspections
and that would take a great deal of time
away from our home base, from our own health system.
And then, finally, there was the cost.
As we compared all of these things,
the advantages and disadvantages of the different accrediting agencies,
The Joint Commission was the clear winner.
I'll be perfectly honest,
I'm going to tell you what I started off by saying:
I have a 45-year career and I had never--
and I've worked in a number of different laboratories,
and I had never worked in a laboratory that's Joint Commission accredited.
Although, I was on that team
and I was the person that came back to the larger group of directors
and I said, "After our discussion,
it really sounds like Joint Commission is the right choice."
And then we did vote to go that way.
It wasn't something that everybody immediately rallied around
because there is reluctance to change.
If we could move forward one slide,
if there's one thing we know,
that is when we feel comfortable and confident,
we feel that our laboratories are in good shape,
we might be reluctant to try a new process
that would cause us a lot of unknowns, a lot of...
Accreditation is such an important part of of what we strive for
and we work toward,
and therefore, we can see that it was a bit concerning.
But we were told that we would, again, all the directors across Ascension,
we were told that we were going to get this done and we got started.
That wasn't something that was driven nationally.
That was-- my health system went out
and I was connected with a wonderful Joint Commission manager.
So if I'd had some trepidation,
many of you are already Joint Commission accredited,
those of you that are listening right now,
and I assume you also were connected with a wonderful person
to guide you through that beginning process.
Our Joint Commission manager that met with us,
it was like they were holding our hand with a big smile on their face
and they were so knowledgeable and reassuring.
It certainly made that beginning part of the process
much easier, always being available to answer our questions.
They trained us on and walked us through the Joint Commission Connect website
and we found it to be a perfect resource.
It was really a one-stop shop.
And as I've noted on this slide, we have more than one lab right now,
we have four hospitals,
and it's so easy to toggle between them within their site,
and all the resources are there.
And those individuals within my hospital and my health system
that guide all Joint Commission work, they can see everything as well too.
I'm connected through our quality team
that are also very involved with The Joint Commission.
And we all have access to this same Joint Commission Connect site
and we can all see and participate and work together
to drive the this accreditation process
with my whole health system involved at the same time.
Let's move on one more slide.
Preparing for our first survey, again, I'm telling you,
I think you and I are probably the same laboratorians,
we'd like to get an A+ on our report card.
I like to be the lab director that has a really flawless survey process,
so now, I have a whole new rule book,
and the rule book looks pretty thick to me, I have to confess,
so I was a little bit worried.
But what we did was just systematically take the standards
and the elements of performance
and break them down into those chapters or sections
and and we bit them off one at a time.
We would all review,
take notes on things that we thought we might have questions about,
meet and discuss them.
And then we were, as I've noted on this slide,
able to turn to Joint Commission at this same Connect website
and type in our questions and get answers.
"On this particular standard,
we I think that what we have here, X, Y, Z would meet that standard.
Could you help guide us? Are we thinking about this the right way?"
What we found is that the answers those questions were really quickly provided.
There was fast turnaround time,
and they were so gracious in their responses, very detailed,
and we felt really comfortable.
As we dived again into those different chapters within the standards
and elements performance,
we certainly found those that were lab specific
that seemed just like maybe things we're very used to
with our previous accrediting agency.
But we saw others that really would require us to partner more openly
and have a stronger connection with our nurses.
And many for a more system-wide...
with all the departments of our hospital.
Not that we were siloed,
I don't really feel like our lab was totally siloed,
but to certainly look at our accreditation process
as a way of connecting with all the rest of the health care providers
within our organization.
It certainly, as I've noted on this slide, initiated a lot of dialogue
with the other departments in our laboratory.
I have to say we still, of course, felt nervous.
I always feel nervous when the big test is coming up, if you will.
And that's not a bad thing, but diving into these standards,
going through the elements of performance
and connecting with others around our organization,
our hospitals of course are all Joint Commission accredited.
There are others in the hospital,
although they weren't seeking lab accreditation,
they were used to the Joint Commission process
and they were able to, again, work with me,
as we connected to assure that the laboratory
was meeting all these standards of performance.
If we could move on...
We found that that The Joint Commission Connect website was just...
that tool was absolutely amazing.
There, we found the Joint Commission survey activity guide
and it just helped us to know exactly how to prepare.
by telling us what documents to have ready,
what that opening conference was going to be like,
what the basic flow of the survey would be like,
and all the elements that we were going to be going through,
perhaps for the very first time, but what to expect.
So, it was perfect for the us as a first-time group.
We took advantage as it shows in the lower half this...
It shows the example that I'm using here
of those annual top standards non-compliance data,
telling us each year...
You can look at that report,
it tells you which standards are most commonly...
do laboratories struggle with,
so that we can really focus some attention on those.
We figured if other labs had trouble with those,
so would our lab.
And we used that to drive a lot of our discussion and preparation as well.
And then as we advance to the next slide,
we'll see that my team really loved these heads up communications that come out.
This particular one is very small type,
but it's just an example to prompt me to talk about it.
The maintenance and inspection of laboratory equipment
was the topic of this particular one.
They've got this great box down below that talks through what could go wrong.
And as you look at the failures of perhaps some other labs
to meet that standard
and you see what wasn't good, you can think about,
"Ah, do I have all of these things in line at my organization?"
I remember another great heads-up was on critical result reporting
and my team learned a lot from that one
about the way The Joint Commission was going to approach
and look at critical result reporting.
So, we were on the same page with them.
Between the survey guide that I mentioned in the last slide
and the work with others within my organization
and documents like these heads up,
communications from Joint Commission...
We felt basically prepared.
As we advance to the next slide,
you'll see that I've alluded to one of the biggest advantages for us,
switching to Joint Commission,
was that it really became much more of a group effort.
When I say Joint Commission within my organization,
within my health system and these four hospitals that I have here,
everyone, literally everyone pays attention,
everybody's on the same page with me, everybody is willing to jump in and help
because they all understand the importance of Joint Commission accreditation
to the health care that we provide, to the quality that we provide,
to the assurance that we're providing the very best care for our patients.
Whether it was in the C-suite, like the CEO, or my boss,
the COO, our Chief Medical Officer our Chief Nursing Officers,
they were there for me to help get questions answered
and to prepare our physicians and providers.
All of our physician leaders know exactly what is expected of Joint Commission.
They're not all experts in the lab standards,
I'm expected to be the expert on the lab side of things,
but remember, I looked at this as much more of a group effort
and we certainly found it here.
Our Director of Accreditation and Regulation
for our entire health system,
her and her team, which they slot themselves
into our Total Quality Management team.
They were right there by our side.
In fact, there is a Quality Nurse
who is in charge of our Joint Commission inspections,
whether those are the hospital ones,
whether there are disease-specific or now at the lab,
she was right there to organize things.
She organized the room for me, she helped set up the lunch.
She knew how the flow would be,
even though she wasn't going to maybe be the expert
on the specific standards;
we were going to be the expert on that.
And so, from our safety officers, our plant facility teams
and really our frontline nursing staff, our OR,
everybody was on board, and in a way,
it felt like we were as a group preparing for this inspection,
for this survey, excuse me.
As we advance to the next slide,
the day then arrived, and since we were brand new,
we did have an announced inspection.
We knew exactly what date we were preparing for
and our survey team did arrive.
And those surveyors,
I would describe them as I have here,
as being extremely experienced and well trained,
extremely fair and unbiased,
and certainly punctual and well-organized.
And this is not to say
that our previous accreditation inspections or surveys,
that were made up of our peers,
that these individuals weren't professional individuals,
that weren't punctual.
But this had a totally different feel.
And immediately, out of the mouth of the lead surveyor
was the idea that the focus of our experience
of these days that were ahead of us were going to be an educational focus.
And the surveyors took a great deal--
they knew that we were new, so they took a great deal of time
to help explain what their focus would be,
again, and assuring that we felt comfortable, I think.
As I've noted here, during this process of days,
and again, this happened at each of our laboratories,
they went out and engaged during part of this time
directly with my team
to stop and teach them something.
And teach might be the wrong word, but to help them look at something.
Let me just think of an example,
they went out into one of our laboratories
and they talked about the manual clipboard.
We have a clipboard where we would record some manual test results.
And then from that clipboard, we would take those results
and they would be entered into our LIS.
And we talked about that,
and was that the best way we should approach it?
Could we live without that clipboard?
Does that clipboard perhaps open us up to potential inefficiency or error?
And engaging my team in that conversation,
that was different than we'd experienced ever before.
Really, we're just thinking out loud with our laboratory team,
not really necessarily saying what's right or wrong.
There's many ways to meet the standards, and we were meeting the standards.
The key was, are there some other ways to approach these things?
And I think that is what we discovered, that sharing of new ideas came up.
It was really a positive and encouraging environment
throughout the experience.
It was a wonderful survey experience for us.
I can see that I'm running out of time, so I'm going to very quickly note that,
as I've noted, it was a new approach for our team,
the surveyors led us through those laboratory tracers,
which were a little bit like our old process.
And then our... those individual tracers,
that really took us into the patients' chart,
that really took us out into the various areas of the hospital.
We interact with physicians, we interacted with nursing,
we went right into the electronic medical record
and it really engaged the laboratory,
much more with the rest of the hospital team
that we had in the past.
As we go on to the next slide,
and then if we could... I've already spoken about this one,
sorry, let's go on to the next one.
I really feel that "Stronger together"
is how I would like to finish out my state--
my description of what happened,
and that is my laboratory associates became much more engaged
with the rest of the hospital.
Not that we weren't engaged already,
I feel proud of the engagement level that we already had in our involvement,
but whether it was with nursing or the quality teams
or administration or physicians and nursing,
in every category, we became more engaged.
New lines of communication opened up.
And throughout our health system,
I feel that we benefited from The Joint Commission process.
As we advance to my last slide then, in closing,
I would say that our conversion to The Joint Commission accreditation
helped us to unite our health care team
the laboratory with the rest of the healthcare team,
and an improved our communication
and our understanding across our health system.
And we clearly, through that greater collaboration,
are going to experience a greater quality of care for our patients,
greater patient safety and satisfaction.
And I am certain that as we look at the patient outcomes,
they will improve as well.
I started off as a lab director with some trepidation
about moving into Joint Commission accreditation,
and now, I'm being a spokesman right here in front of all of you
to say I'm so glad we made the change.
I apologize that I was muted at the beginning
and I've delayed us for questions.
I'm going to turn it back over to Sharon though
to see if we still have time for questions.
(Sharon) We sure do. Thank you so much, Lynnette.
We are now going to begin answering any questions that you may have for us.
As a reminder, you can submit questions
by typing them into the questions box of your control panel.
And we'll take a couple of minutes here going over any that we don't get to,
we will personally reach out to you via email.
And the first question is going to go to me,
"Is the first survey announced?"
Yes, your initial first survey with us is announced.
You can preference a ready date in your application with us.
We try to schedule within 30 to 60 days after your ready date
and you will get a 30 days advanced notice of that start date.
The second question is going out to Lynnette.
"Lynnette, how did you get everyone in your laboratory on board
with the transition to The Joint Commission?"
(Lynnette) Well, I am the director for the entire health system,
so I simply broke my...
I did select a few key leaders that would help to lead this transition.
And again, we met as groups to go through all of the standards.
We just had meetings.
This week, we're going to meet on this group of standards.
Everybody would have read it in advance, we discussed our questions,
and then we actually created spreadsheets
to say what was our next step on some of these.
Some we just checked off and said, "Done. We know we've got that one."
(Sharon) Thank you.
This one is going to go to myself,
"Is the Joint Commission lab inspection
concurrent with the Joint Commission hospital inspection?"
They're actually done separately,
and that's because federally, every two years,
laboratories need to be seen,
and the hospital visits are done every three.
There are some organizations that do requests every six years
that we land the hospital and the lab team together, unannounced.
But that's really up to you.
We don't try to staff those together concurrent in any manner.
This next question is going to go to Lynnette.
"How many days were your survey, Lynnette?"
(Lynnette) At our smaller hospitals, they were only two days.
My smaller hospitals are around 100 to 150 beds,
and I think that...
Gee, is that funny that I can't pu...
It depends on the number of inspectors that they send...
Excuse me, surveyors.
So, depending on the size of your surveyor team,
I think our shortest inspection was two days
and our longest one was four days.
(Sharon) Thank you. I have another one,
and you touched a little bit about the survey tracer process.
"How did you prepare your laboratory for those tracers?"
We have a tiny bit of experience because we participated in hospital ones as well
and we would be asked to come to a tracer for a blood bank or something.
So, we knew a little bit about what it would be like,
but to be honest, I didn't probably know what it was like,
and I just-- the surveyors made it-- they taught us how to think about it.
And we had a nurse navigator with us.
We would go and they would say,
"Okay, bring me three criticals," from, some peer, some dates or something.
You go get those three criticals,
they would look them up on the in the electronic medical record
and then that would be the pivot point.
We might go visit that unit,
we might see how it looked in the record, was it called on time,
and everything would bounce from there.
It was really actually very exciting.
I don't know that I was perfectly prepared,
but the surveyors, they make it such an educational experience.
I didn't have to be perfectly prepared, it just worked.
(Sharon) Thank you. And this last question before we wrap,
any others we didn't get to, we'll reach out.
This one, I'll take.
The question is, "Are the inspectors peers or professional inspectors?"
They are all hired by The Joint Commission,
so they are all our staff members, fully supervised.
(Lynnette) But can I ask you, Sharon?
(Sharon) Yes.
(Lynnette) They were pathologists
and lab directors,
and often led a lab director's leader team.
They felt just like us.
They looked like they had grown up and had maybe my career path before.
They really exactly new labs and had a long career,
so we've totally respected--
They knew what they were talking about
and they had been perfectly trained by The Joint Commission.
(Sharon) Thank you for that addition.
Go ahead and advance the slide for me, please.
We just want to make sure you know how to contact us
if you have any questions.
There's an email there and there's a website,
and if you go to the last slide here, we just really wanted to thank everyone
for attending today's webinar presentation.
This concludes our presentation.
You will receive a follow-up email about one to two days
with a link to view the slides and recording of our presentation today.
On behalf of The Joint Commission,
we sincerely thank you, Lynnette, for your time today
and sharing some really very valuable insights for our audience,
and thank you to all our audience for joining us today.
Please be safe and be well, and just have a great rest of your day.
Thank you!
(Lynnette) Thank you.