I was presented by my lab manager this question when it comes to F.S. and FNA's, - The key word here is THE ORDERING OF: Does anyone monitor the time in which the specimen is removed from the OR to the time it is called back. Our specimens are delivered to us and clocked in at the time of receipt by the lab to the time in which it is resulted back. In CAP it does not state the "start" in which the TAT is monitored. We are both CAP and JCAHO, Do you have 2 separate policies or do you just use your CAP policy?
The [organization] measures, assesses, and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver.
Elements of Performance for NPSG.02.03.01
1 The laboratory defines critical tests and critical results and values.
2 The laboratory defines the acceptable length of time between the ordering of critical tests and reporting the results of these tests, whether normal or abnormal.
3 The laboratory defines the acceptable length of time for reporting the results of routine tests with critical abnormal values or findings.
4 The laboratory defines the acceptable length of time between the availability of critical tests and critical results and values and receipt by the responsible licensed caregiver.
5 The laboratory collects data on the timeliness of reporting critical test results and critical results and values from routine tests.
6 The laboratory assesses the data on the timeliness of reporting critical test results and critical results and values from routine tests and determines whether a need for improvement exists.
7 The laboratory takes appropriate action to improve the timeliness of reporting critical test results and critical results and values from routine tests and measures the effectiveness of those actions.
8 Critically abnormal test results are communicated quickly to a responsible licensed caregiver so that prompt action may be taken.
9 When the responsible licensed caregiver is not available, a back-up reporting system provides the information in a timely manner to another qualified responsible caregiver to prevent avoidable delays in treatment or response.
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