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Press Start: Lead an Empowered Life as a Clinical Laboratorian

How to Maintain a State of Continued Readiness

Published February 4, 2013 8:28 PM by Glen McDaniel

Generally I change the battery in my smoke detectors each year on the date we "fall back" to return to Daylight Standard Time 

I use this date as a convenient memory jogger to make sure I always have fresh batteries in what an essential part of my home emergency system.  I need my alert system to be fully functional in case I need it; before I actually need it.

Regulatory agencies like The Joint Commission and  College of American Pathologists  (CAP)  require that organizations they accredit be in a state of continuous readiness as well. CAP inspects laboratories on a biennial basis but require that during the off year each lab conducts essentially their own mock survey, documents its findings and makes adjustments to address any deficiency found. Joint Commission requires a similar Periodic Performance Review (PPR) in which the organization self-surveys and turns over its findings (warts and all) to the Joint Commission.

The other aspect of being on "ready alert" is that surveys are unannounced so that organizations are encouraged to "embed" standards into daily operation to the degree they will not be surprised or thrown off if a surveyor suddenly shows up.

While this is a great concept, many labs still dread a survey and ramp up activities and self-inspection when a survey is anticipated. The problem with having lax standards is that after a while deficiencies become background noise and are not even noticed.

A consultant who helps to keep organizations constantly ready suggests that one way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Survey process conducted by someone external to your organization. This ‘someone' could be a consultant or an experienced peer professional from a neighboring facility. If, however, you elect to manage the process using your own personnel, incorporating the following approaches can facilitate objectivity:

 - Assign department heads to ‘survey' departments other than their own.  It is often hard to see your own forest for the trees. Let them use the official accreditation/regulatory standards to see how each department stacks up.

- Even if the staff knows that a Mock Survey will be taking place at some point, it could be more beneficial if direct care staff and other workers were not informed of the exact timing

- Even though the internal ‘surveyors' know that the process is planned, the Mock Survey itself should be unannounced. An administrator or Lab Director walks in one morning and proclaims it to be Mock Survey Day. This element of surprise simulates the unannounced survey.

Get the entire staff involved in a plan of action listing deficiency, responsible party, time frame and so on. Use deficiencies as an opportunity for education. Change procedures and processes if warranted. For example using the "tracer methodology" following a few specimens from collection to resulting might provide valuable information about areas of vulnerabilities or point to areas where improvements are needed.

She suggests that doing this a couple (or more) times each year will keep standards fresh in the mind of employees, make them more attuned to deficiencies that would otherwise be overlooked and also conditions them to take an "inspection" in stride.

If you think about it, it's like changing that battery before you really "need" to.

4 comments

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Dolly Dolly, aMQKNwvTBnxEr - DInHlOTGcyBzGij, szjxqOXDBUx March 2, 2013 6:10 PM
yFoOBqvbfmJxdiWuAd AZ

I am in lab management and we do our annual self inspection. It's not that we dont check ourself. It's that CAP does not verify what we do.

In all my years of being insepcted I have never been asked to show my annual Internal Inspection documents. I have served on survey teams for CAP and I dont know of anyone on the team who asked the lab we are inspecting to show their documents.  You might ask for areas of challenges and you definitely look at their last CAP survey results from 2 years prior.But what about their self survey from last year?

Done well it is a good tool. But it can be done shoddily  or not all and no one would know the difference. I am just saying...

Sharma T February 6, 2013 9:27 PM
San Antonio TX

At my current job we do fire drills and disaster drills. We also get feedback so we can know what to do in a real emergency. But every time we do it someoen still messes up.

It is always confusing who should do what. What department reps should go to the Command Center in Adminstration. For those left in the lab, who does what. We hear it did not go smooth, but never learn what the right thing is.

I know why we do a drill it is in case of an emergency, fire or disaster. But since you are talking about  JCAHO do they even ask if you had drills and how the drills go? You could pass inspection and not even know what to do in a disaster or fire.

Belinda S. February 6, 2013 6:47 PM
Atlanta GA

We prepeare but not in such an organized fashion. For example one month we will concentrate on checking that thereare no expired tubes and supplies, another month we check open reagents all dated and temperature charts complete. That way we hit almost everything at some point.

Hospital Quality Management also does environmental rounds periodically  where they check that inventory items stored off the floor, there is clearance from the ceiling in the stock room, no water stained ceiling tiles etc.

It would be a good idea to go through and do a full out mock survey. But who has the time?

Jonathan Thomas February 5, 2013 11:25 AM
Denver CO

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