[Histonet] tissue retention times

[Kolman, Kimberly D.]

We are a small Mohs operation, but we just process and paraffin block
all our remaining specimens and file them with the rest of our pathology
cases.  This worked for CAP anyway.

Kim Kolman, HT, (ASCP)
VA Eastern Kansas Health Care System
Leavenworth, Ks 66048

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu
[mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Ingles
Claire 
Sent: Thursday, January 21, 2010 12:11 PM
To: histonet <@t> lists.utsouthwestern.edu
Subject: [Histonet] tissue retention times

OK, everybody crack open your JCAHO requirement manuals...
We are a MOHS lab and were surveyed by Joint Commission about 2 months
ago. During the survey, we were cited because we only retain our
physical tissue specimens for 24 hours, as they remain fresh and are not
fixed. We throw the tissue the following afternoon vs. retaining for the
"1 week after microscopic sections are examined and reports are reviewed
and signed." (Standard #QC.2.120) 
Has anyone else (specifically a Mohs lab) been cited for this? We are
currently trying to appeal, but have been denied so far. I am having a
teleconference with the JCAHO powers that be to try and get the appeal
going again, but I'm not the lawyer type.
The letter states that their interpretation is that even if the tissue
is not regarded as 'gross' tissue, any 'useable' tissue must be retained
for a minimum of a week after the case is signed off on.I am thinking on
focusing on the 'useable' bit as related to diagnostic value of delayed
retained fresh tissue processing i.e. freeze artifact, tissue
degredation, inability to perform ancillary testing, etc. Also, what is
the definition of 'reviewed and signed reports'? Does this mean when the
case is finalized, or just the tissue sections in question? We sometimes
have patients that go a month + between Mohs procedures on the same
positive lesion.
We will probably have to get a -80 freezer for this if the appeal
doesn't go through. Not to mention the fact that some of our cases are
not resolved for months. We would have constantly search when cases are
finalized to know when we can dispose of the tissue. FYI, the letter
also states that the JCAHO standard is more stringent than the CLIA
standard, so I'm not even really going to use it in arguments. 
 
HELP!
Claire Ingles
UW Hospital & Clinics
Madison WI
 

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