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
Sent: Monday, May 10, 2021 6:07 AM
To: histonet@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 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, 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.va...@lkmc.com |
Tel: 305-294-5531 x4736 I
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