Jessica,
in my experience, CAP trumps JCAHO. Every hospital that I've worked in that
the lab was accredited by CAP, JCAHO left the lab alone, except for taking a
walk through and maybe asking some safety questions.
JTT
----- Original Message -----
From: "Vacca Jessica"
To:
Sent: Monday, November 17, 2008 1:05 PM
Subject: [Histonet] JCAHO question
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?
NPSG.02.03.01
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.
Jessica Vacca
Histology Supervisor
119 Oakfield Dr
Brandon Fl 33511
(813) 571-5193
(813) 571-5169 FAX
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