[Histonet] JCAHO labs

[Morken, Timothy]

Jessica, CAP and JC apply the same CLIA regulations, just in a different manner. CAP tends to apply more of their own "upgrades." Ie, makes it a bit stricter, which is allowed. CLIA is just the baseline. If you have been thru CAP inspections you will not have any problem with JC. 

While CAP will campout in your lab for several days and look at EVERYTHING, JC relies on "tracers" to get at the same information, just in a random manner. They will give you several specific dates during the past two years  and then ask for a number of random cases per day. Then they want to see everything you have that pertains to those specific cases. That is from accession logs to final report and everything in between - QC logs of stains and equipment, maintenance logs, service reports, controls for whatever stains were done. All slides and blocks on the case. Records of who did the staining. Personnel records of the personnel doing the work, competency records for those personnel. Everything. Like most inspections, if you can produce what they want quickly they are happy. 

They will also do a walk-through of the lab and ask personnel various questions about safety, where SOPs are, look at chemicals, whether it is too crowded or cluttered, etc. In our labs in 5 JC inspections I have been through here they have never spent more than an hour in any particular lab. But we have many labs, so if they come to inspect your one small lab they will be spending more time there, I imagine. 

None of the JC inspectors we have had come through had any experience at all in anatomic pathology. All were clinical lab techs or administrators. We got dinged for some things that were minor - chips in formica that a microbiology guy thought were infection hazards, to dust on tops of some cabinets. Not much else. 

Our JC inspections last 3-4 days but that also covers many hospital areas and other labs besides histo/cyto/grossing/morgue. We have dozens of labs across many facilities. If all they did was AP they would be done in two days at most. IF you have a very small lab it might be only one day. 

Tim Morken
Supervisor, Electron Microscopy/Neuromuscular Special Studies
Department of Pathology
UC San Francisco Medical Center

-----Original Message-----
From: Jessica Vacca via Histonet <histonet at lists.utsouthwestern.edu> 
Sent: Monday, May 10, 2021 6:07 AM
To: histonet at lists.utsouthwestern.edu
Subject: [Histonet] JCAHO labs

Good Morning!
I was wondering if those of you that are accredited by this entity if you wouldn't mind sharing some information. I've only worked in CAP labs and have a complete understanding of the checklists and have based P&P on those. What/Where do the differences lie and in what items should be more focused on. Also if you wouldn't mind sharing some P&P, QC/QA logs etc.
that would be great. We have some here but would like to see what others may have consolidated etc.

Also we are currently Old School in that we DO NOT have a LIS so everything done here is offline, so in regards to specimen searches, IHC positive stains and Cytology QA is all done manually if you have figured an easy way to do this or can guide me in a process that would work, I'd love to hear your thoughts. I have been on the IT side of things for hte past 12 years and the hospital that I am PRN'ing at needs desperate help in getting some/alot of things done online or availabe on ss that can be easily searched.

Equipment/Process:
Peloris
Ventana ultra
Cytology (manual Process)
Special Stain (Poly Kits)
Leica Stainer

Thanks in advance for your help!

-- 

*Jessica Vacca  |Histology Technologist  |  Lower Keys Medical Center | *

5900 College Road   I   Key West, FL   33040   I | Jessica.Vacca at lkmc.com |
Tel: 305-294-5531 x4736   I  https://urldefense.com/v3/__http://www.lkmc.com__;!!LQC6Cpwp!4zmFXwgQHzwbpmPjmD9Vt_u3ESjTyQWRS_M16OLGK30HxLOqahEHjxFJ5h_gRWbxdY057A$ 


This is a confidential patient safety work product communication.  It is protected from disclosure pursuant to the provisions of the Patient Safety and Quality Improvement Act (42 CFR, Part 3) and other state and federal laws.  Unauthorized disclosure or duplication is prohibited



*Disclaimer*:  This electronic message may contain information that is Proprietary, Confidential, or Legally privileged or protected.  It is intended only for the individual(s) and entity named in the message.  If you are not an intended recipient of this message, please notify the sender immediately and delete the material from your computer.  Do not deliver, distribute or copy this message and do not disclose its contents or take any action in reliance on the information it contains.
_______________________________________________
Histonet mailing list
Histonet at lists.utsouthwestern.edu
https://urldefense.com/v3/__http://lists.utsouthwestern.edu/mailman/listinfo/histonet__;!!LQC6Cpwp!4zmFXwgQHzwbpmPjmD9Vt_u3ESjTyQWRS_M16OLGK30HxLOqahEHjxFJ5h_gRWaYVh8hCA$