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Preparing for your First JointCommission SurveyStacy Olea, MBA, MT(ASCP), FACHEExecutive Director LaboratoryAccreditationApril 23, 2015

Objectives Describe The Joint Commission Laboratorysurvey process Explain Tracer Methodology Create mock tracers to use in yourorganization Identify the resources available to assist withsurvey preparation and continuouscompliance2

The Joint Commission3

The Joint Commission’s VisionAll people experience the safest, highest quality, bestvalue health care across all settings.The Joint Commission’s MissionTo continuously improve health care for the public, incollaboration with other stakeholders, by evaluatinghealth care organizations and inspiring them to excelin providing safe and effective care of the highestquality and value.4

What is unique to our surveyprocess? Employed surveyor cadre Concentration on the operationalsystems that directly affect the qualityand safety of diagnostic services National Patient Safety Goals Tracer Methodology Lab Central ConnectTM5

Employed Peer SurveyorCadre Requirements to be a Laboratory Surveyor– Bachelor’s Degree and certification– Master’s Degree– 5 years clinical laboratory management experience– Experience in 3 areas/specialties Surveyor training– Initial– Ongoing Life as a surveyor– Types of laboratories– Quantity of laboratories– Performance monitoring6

Operational SystemsApproach Our mission and vision drives us to look at how thelaboratory is integrated into patient care Standards consistent across all programs We will spend time outside of the laboratory– Nonwaived ancillary Point of Care Testing sites– A sampling of waived and PPMP Point of CareTesting sites– Hospital/Clinic Integration– Patient Medical Record– Infection Control– Human Resources7

National Patient Safety Goals NPSG.01.01.01 Two Patient Identifiers NPSG.02.03.01 Critical Results NPSG.07.01.07 Hand Hygiene8

Tracer Methodology Uses actual patients as the framework for assessing standardscompliance Individual tracers follow the experience of care through theentire health care process in the organization System tracers evaluate the integration of related processes– Coordination and communication among disciplines anddepartments– In-depth discussion and education regarding the use of datain performance improvement Reference document available athttp://www.jointcommission.org/tracer methodology 101/9

Lab Central ConnectTM Nonwaived CLIAs only Personnel for each CLIA:– Laboratory Director– Technical Consultant (moderate complexity)– Technical Supervisor (high complexity)– General Supervisor (high complexity)– Clinical Consultant (moderate and high) Test Systems for each CLIA Are you accepting outside specimens for testing? Cytology– Workload for all personnel performing primary screening– Annual statistics10

Joint Commission SurveyOptions Anatomical Pathologist Corporate Surveys– Dedicated Team– Orientation to your Organization– Annual Summation Simultaneous Surveys– Other Programs– Sister facilities Concurrent Surveys11

E-App Required upon initial application for survey and verifyinformation annually Included information: ownership, demographics, types andvolumes of services provided Drives the anticipated number of survey days, number and typeof surveyors, and survey agenda activities Inaccurate or incomplete information may necessitate anadditional survey and cause the organization to incur additionalsurvey charges Description for calculating non-waived volumes athttp://www.jointcommission.org/Guidelines for Counting Testsfor CLIA/12

Required Documentation Documentation list for your survey– The 24 month reference in the followingitems is not applicable to initial surveys,except for proficiency testing data.– For initial surveys, a minimum of 4 monthsof data must be available for review.13

Required Documentation As a laboratory, you should have the following information anddocuments available for the surveyor to review during theSurveyor Planning Session– Name of key contact person who can assist in planning tracerselections– CLIA Certificates, Specialties and Subspecialties, State Licenses,and personnel license or certification if required by the state ororganization policy– An organizational chart and map of the facility– Ability to retrieve testing records for patients who have hadlaboratory tests or other services for the past 24 months (4 monthsif an initial survey)– Performance improvement Data for the past 24 months (4 monthsif an initial survey)– Proficiency Testing data by CLIA number for the past 24 months14

Required Documentation As a laboratory, you should have the following information anddocuments available for the surveyor to review during theSurveyor Planning Session– Results of periodic laboratory environment inspections from the safetycommittee or safety officer– Manifests for the disposal of hazardous waste for the past 24 months (4months if an initial survey)– A list of specialties and subspecialties performed by the lab– A list of tests performed (test menu) and instruments used including allancillary and point of care sites– Measures of Success (MOS) identified in the Plan of Action from thePeriodic Performance Review– Employee personnel files will be reviewed, including employee educationrecords, competency documentation, and employee health information– Note: Surveyors may need to see additional documents throughout thesurvey to further explore or validate observations or discussions with staff.15

On-Site Survey Activities Surveyor photo, bio and survey agenda are posted to theextranet site at 07:30 local time Depending on the complexity of the organization a surveymay last more than one day and could involve a team ofsurveyors Once the surveyor arrives, the organization’s extranetmust be checked for confirmation of the survey andidentification of the surveyor Preliminary Planning Session Opening Conference Orientation to the Organization16

On-Site Survey Activities A Daily Briefing occurs every morning of a multidaysurvey, with the exception of the first day Competency Assessment Personnel education/qualification verification Regulatory Review Proficiency Testing Validation/Performance ImprovementData Review Individual Tracers (60% of survey activity) Physical Environment Survey Report Preparation CEO Exit Briefing and Organization Exit Conference17

From Survey Report toAccreditation Decision A preliminary report is available on the extranet until midnightof the day the survey has been completed. The accreditation decision is not made until all of yourorganization’s post-survey activities are completed The final summary of survey findings report will be posted onyour extranet site.– It will include which findings require an Evidence ofStandards Compliance (ESC) submission within 45 days(direct impact standards) and/or 60 days (indirect impactstandards) Upon approval of your organization’s last submitted ESC, youraccreditation decision is posted to your extranet site and toQuality Check (www.qualitycheck.org)18

Corrective ESC An acceptable corrective ESC report must detail the following:– Action(s) that the organization took to bring itself into compliancewith a standard– The title of the person(s) responsible for implementing thecorrective actions or approving a revised policy, procedure, orprocess– Compliance at the EP level and include a Measure of Success(MOS) if applicable Measure of Success (MOS)– A numerical or quantifiable measure, usually related to an audit todetermine if action was effective and sustained– Due four months after notification of an acceptable ESC– Not required for all ESCs19

From Accreditation to ContinuousCompliance with the Standards Concentrate on incorporating the frameworks andconcepts of standards and EPs into day-to-day workrather than viewing the concepts as rules that mustbe followed Read Perspectives each month to identifynew/updated standards, scoring, standardsinterpretation Sign up for E-Alerts Keep Lab Central ConnectTM updated Complete your Intracycle Monitoring Contact SIG to submit standard questions20

Tracer Methodology21

Before Tracers Records review No link to patientcare22

Tracer Methodology Surveyors evaluate the following:– Compliance with standards and National Patient SafetyGoals– Consistent adherence to policy and consistentimplementation of procedures– Communication within and betweendepartments/programs/services– Staff competency for assignments and workload capacity– Personnel requirements– The physical environment as it relates to the safety ofpatients, visitors, and staff23

Tracer Methodology Patients are the framework Follows the experience of care Begins with a test result Includes preanalytics and postanalytics Involves multiple staff, the patient, and even familyto learn details about an individual’s health careexperience Specialties and subspecialties for a 2 year period– 13 – 24 months– 6 – 12 months– Within the last 6 months24

Starting Points Common starting pointsfor tracers– Patients who cross settings– Critical results– Point of care testinglocations– Direct observations– Proficiency Testing results– Abnormal results– Kit testing– Tests that use e-QC25

Documents Reviewed Documents reviewed– Instrument maintenancerecords, calibrationverification, qualitycontrol, correlations– Policies and procedures– Employee competencyand qualifications– Process improvement– Patient medical records– Waste disposal records26

Interview laboratory StaffAbout Processes andcompliance withstandards Intradepartment andinterdepartmentcommunication Address data use Processes and roles tominimize risk National Patient SafetyGoals Orientation, trainingand competency Awareness ofAPR.09.02.01 Workload issues Validation ofinformation learned27

Interview Others About Physicians/Nursing Staff Inquire if laboratoryservices/tests offeredonsite are adequate Communication andcoordination when newtests are added and whentest reports change Ascertain what iscommunicated and bywhat methodPatients and Family Coordination of servicesincluding timeliness Education provided Perception of services Understanding ofdischarge instructionsfollowing an outpatienttransfusion Staff compliance withNPSGs28

Completing the TracerObserve Potential environmentalissues Sample collection Transfusion POCT Infection controlprocesses ProcessImprovementAfterwards Review meeting minutes Review procedures Pull additional records ifnecessary29

Chemistry, Hematology, &Coagulation Quality Control Maintenance records E-QC Policy and Procedures Calibration andCalibration Verification Lot numbers in use Correlations Validation of newinstruments/methods Surveillance of patientresults, quality controlresults, and instrumentpreventative maintenance Documentation oftemperatures Environment of Care Patient medical record Coagulation: ISI andNormal Patient Mean NPSGs30

Serology, Virology,Immunology, Molecular andUA Quality Control Maintenance Temperatures Lot numbers Patient medical record Validation of new methods and instruments Surveillance of patient results, quality control results, andinstrument preventative maintenance Environment of Care NPSGs31

Waived Testing Outside thelaboratory Patient medical record quality control (internal and external) Reference Ranges Lot numbers NPSGs Environment of Care Policy and Procedures Maintenance Temperatures32

Patient Medical Record Order for the test Reference Ranges Name and address of the performing laboratory Consents Order to transfuse Preliminary Reports Intra-operative Reports Documentation for critical results Final report for transfusion reactions Tissue record documentation33