The laboratory at John T. Mather Memorial Hospital (JTMMH) in Port Jefferson, New York (USA), however, recently completed its JCAHO survey and, for the second time in the past decade, proudly reported a perfect evaluation—thanks in large part to the lab's streamlined processes, lean best practices and comprehensive automation solution from Beckman Coulter.
Laboratory Under the Microscope
Since JCAHO lab surveys are required every other year and the JTMMH laboratory was last surveyed in July 2004, the lab knew it was due for another visit at any time. The exact day, however, was a mystery.
The anticipated survey became reality on July 18, 2006, when the lab learned that the surveyor was not only on her way, but that the two-day survey process was to begin in less than an hour.
Tracer Methodology at Work
After arriving right on schedule, the JCAHO surveyor quickly began her work, using a process known as tracer methodology. Essentially, this process involves “tracing” the patient's stay—from point of entry to post-discharge and all points in between.
For example, during JCAHO's survey of the hospital only a month before, the surveyor observed an ICU nurse drawing blood samples from a patient who had also just completed a fingerstick for bedside glucose monitoring. The surveyor then followed those sample tubes from the patient's bedside through the entire testing process, including sample order, draw, tube labeling and delivery to the lab.
Next, the surveyor visited the lab, so she could witness what happened in the laboratory after a test was ordered from the hospital floor. Specifically, she was interested in how the lab generates a barcode label and how the process ensures positive sample identification and appropriate tube labeling at the bedside—using two unique identifiers as specified by JCAHO's National Patient Safety Goals.
She also evaluated the time it took for those samples to arrive in the lab and the turnaround time for the test results to be reported back to the floor. This entire process required only 20 minutes.
The surveyor then compared the patient's bedside glucose monitoring result, which in this case was 318, with the blood sample result from the lab, which the lab reported back as 320.
“She was very impressed with the speed of the laboratory's turnaround time, as well as the close correlation between the results from the bedside glucose monitoring and the blood analysis from the laboratory,” explains Denise Geiger, Ph.D., Administrative Director of the laboratory.
Stellar Results
At the end of the two-day process, the JCAHO surveyor conducted an exit interview with the hospital's senior management team and provided the survey results and JCAHO findings.
For most labs, these findings often include recommendations for meeting National Patient Safety Goals—specifically, proper patient identification, increased communication between caregivers and efforts to prevent medication errors.
In the case of JTMMH, however, the surveyor informed the laboratory they had received a perfect evaluation, with no specific recommendations for improvement, no follow-up issues and no supplemental items requiring attention.
“In the past, JCAHO assigned numeric scores to their surveys, but in 2004, the Joint Commission eliminated performance scores—shifting the focus from passing the exam to continuous operational improvement,” explains Geiger. “So even though we didn't get a numeric score, the fact that JCAHO did not list any recommendations says that they found our lab's systems of safety and quality of care to be in full compliance with their standards and elements of performance.”
The lab's first perfect JCAHO score came in 1998, but Geiger explains a lot has changed since then.
“Today's regulatory environment is a lot more complex than it used to be and requires more stringent patient safety goals than ever before,” she said. “For me, this JCAHO survey score was one additional affirmation of our recent changes—the most important being our adoption of laboratory automation in 2001.”
After installing Beckman Coulter's Power Processor automation system, the lab increased total testing volume by 82.6 percent, while maintaining the same number of lab employees. It also witnessed a 152 percent increase in revenue, a 17 percent decrease in cost per test and a 79 percent reduction in drugs-of-abuse turnaround time.
“As part of our lean process improvement efforts, we viewed the adoption of automation as a cost-effective way to improve our processes, increase productivity and lower overall costs,” explains Geiger. “Beckman Coulter's automation system offered the most comprehensive solution to our ongoing efforts, which are validated every day by keeping us inspection-ready at all times. We are very pleased with our latest JCAHO results and attribute much of our success to our best practices and our automated processes.”
About John T. Mather Memorial Hospital
John T. Mather Memorial Hospital is a not-for-profit hospital in Port Jefferson, New York (USA), situated on the north shore of Long Island in Suffolk County (population 1.4 million). Since its establishment in 1929 as the first community hospital in its area, JTMMH has continued to meet the changing healthcare needs of the community by pioneering programs unique to a community hospital.
JTMMH gained another first in February 2001 when it became the only hospital on Long Island , and the only community hospital in the entire northeast region, to be equipped with a state-of-the-art, fully automated, in-house laboratory robotics system. |
