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After decades of using The Joint Commission for their laboratory accreditation, Memorial Hospital and Health Care Center still finds each survey a useful tool in delivering high-quality laboratory services.

For more than 65 years, the staff at Memorial Hospital and Health Care Center have worked to provide the communities they serve with excellent health care services. They consider The Joint Commission vital to that mission. That’s why they use The Joint Commission to accredit their laboratories to meet the Clinical Laboratory Improvement Amendments (CLIA) requirements.

,,During a recent survey we found out that we were interpreting a standard a little differently than intended. Our surveyor worked with us and showed us how to improve the process and helped us fit that into our workflow. It was great because we actually saw the rewards of that work in the following survey when we were commended on our proactive approach to displaying data.,,

Beverly Dekemper MT (ASCP) - Director of Laboratory Services - Memorial Hospital and Health Care Center, Jasper, IN

Q: What is the biggest benefit for achieving Joint Commission laboratory accreditation for Memorial Hospital and Health Care Center?

A: I believe there are three significant benefits. The most important is the education process it provides employees. Through our preparation and orientation of new employees, the standards help guide them to understand why process is so important. Then, during the survey, the one-on-one interaction with the surveyors allows them time to discuss the “why” behind each standard and really embrace what it does to improve our quality.

The next thing it does, that any laboratory manager or quality director will understand, is it takes the standards and quality assurance work beyond the laboratory doors. Departments such as emergency room, ICU or medical practices are part of the laboratory survey process. The onsite survey highlights how important every step of the testing process is to ensure consistency and patient care.

Finally, we learn from the surveyors and hear about industry best practices so we can improve upon our processes. The surveyors work with our employees to teach them how to improve by telling them what other organizations consider best practice. We then incorporate those ideas into our workflow. The relationship with The Joint Commission is about learning and improving to provide high quality patient care.

Understanding the Standards

Our work with The Joint Commission helps our employees understand the “why” behind each standard.

Takes Standards Beyond the Lab

The survey process helps departments that utilize the laboratory understand the requirements for a high-quality testing facility.

Learning Best Practices

The surveyors are constantly working with our employees to teach them how to improve and what other organizations consider best practice.

Q: How do you prepare for a survey?

A: At Memorial Hospital and Health Care Center we truly live by the mantra “always ready”. In order to provide quality laboratory services every day, to every patient, we have to be survey ready at all times. We are constantly reviewing processes and our workflow to ensure we are ready and on task. The biggest preparation we have is orientating new employees to the standards and processes. We work with them to understand the standards and the documentation that may be necessary during the survey so they are prepared should we have an unannounced survey. It is our goal to bring new employees to survey readiness fairly quickly.

Q: What did your staff learn during the accreditation process?

A: I have a specific example of something we learned on a recent survey. The surveyors were on site reviewing our cytology workflow. This was a workflow and standard we thought we were executing correctly. During the survey process, we found that we could really improve the way we were displaying data. At the time, we were interpreting the standard slightly differently than was intended. The process for improving our workflow is a collaborative effort between our staff and Joint Commission surveyors. They helped us understand what was insufficient about our current process and taught us best practices for exhibiting data. We were able to improve our processes and therefore improve our quality