Missouri health center survives thorough lab inspection

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Unannounced survey

Uses RFI as education opportunity for staff members

After reading this article, you will be able to:

  • Discuss how lab calibration points affected a Missouri hospital’s survey results
  • Identify challenges with specimen labeling during this survey
  • Discuss the use of shadowing to prevent future RFIs

On September 23, 2009, Cindy McKeon, BS, BSMT, MS, MBA, ASEP, lab director at Bothwell Regional Health Center in Sedalia, MO, received the greatest birthday news one could hope for while being surveyed by The Joint Commission: You are accredited for two more years.

“After the three days the surveyor spent reviewing the lab, it was the only thing I wanted to hear,” says McKeon.

The survey, performed September 21–23, took a thorough look at Bothwell’s lab in regard to all Joint Commission standards with a focus on quality control and the National Patient Safety Goals.

“The surveyor’s main concern while reviewing the lab was patient identification and labeling specimens in the presence of the patient, while the rest focused on quality control standards,” says Connie Chappelle, MN, RN, C, CLNC, risk manager/regulatory compliance coordinator at the health center.

Thorough inspection of lab and processes

Upon arrival, the surveyor had an opening session with Chappelle, McKeon, and Bothwell’s CEO. During this session, the surveyor asked questions about the organization and then went to the lab for surveying.

“She was very meticulous, right down to the statistical review,” says McKeon. “One example of this was the calibration and verification standards the lab was using.”

Bothwell’s lab calibration points met those set by the vendor, but the middle calibration point did not fit what the surveyor felt was acceptable.

The surveyor also commented that there was no outline in the policy stating exactly how the middle calibration point would be determined.

“When I wrote to The Joint Commission and asked them to help clarify how to determine the middle range, they told me it was up to me and my facility to determine that,” says McKeon.

Although McKeon appreciates the thoroughness of surveys, she wants more guidance when it comes to seeking out The Joint Commission’s help in clarifying a surveyor’s request.

“When getting a response back from a question, such as clarifying the middle calibration, and having the answer say it is up to me and my facility to determine, what guarantee do I have that I won’t be cited in the future based upon a different surveyor’s interpretation?” says McKeon.

Another suggestion the surveyor made to McKeon and her lab was looking into how their reference laboratory processes the histology slides sent for preparation, which then are returned for review by the medical director.

Chappelle says the surveyor also noted that Bothwell did not have any written transfusion criteria required by the EP.

“Since the survey, we have developed transfusion criteria, and the final version was approved by the medical executive committee in November,” says Chappelle.

Revisiting specimen labeling

Aside from these suggestions, Bothwell only received one RFI requiring a 45-day evidence of standards compliance submission because of failing to label the specimen at the patient’s side.

“It was not because administration was not familiar with the process,” says McKeon. “It was staff members’ feeling they were doing a good job but got too relaxed in their patient safety skills, and this was where the mistake occurred.”

The surveyor cited the lab on this process; two phlebotomists had not followed the process, and the outpatients they were collecting specimens from got out of their seats and started to walk out of the room.

“With this being a Category A in lab accreditation, it only takes one to be considered an RFI,” explains Chappelle.

Taking preventive measures: Shadowing

Both Chappelle and McKeon understood the severity of receiving an RFI for failure to label the specimen in front of the patient and came up with a plan to help staff members understand the importance of this process.

“Once the survey was over and we had written our plan for corrective action, we instituted a direct shadowing program,” says McKeon.

“We had a zero-tolerance attitude towards this and wanted everyone in Bothwell to be on the same page,” says Chappelle.

The program involves all lab leadership shadowing a minimum of five phlebotomists per day across all three shifts at Bothwell, with a focus on peer-to-peer observations.

“The lab leadership had to coordinate their schedules to make sure one of them was at the lab at any given time,” says McKeon.

Since McKeon and Chappelle began direct shadowing at the lab, they have had 100% compliance with labeling the specimen in front of the patient.

“It is important to address the RFI now, because when the hospital goes through their inspection, [the lab] will get reinspected, and you bet the surveyor will focus in on any RFIs we received,” says McKeon.

Preparation for future surveys

For future surveys and keeping staff members prepared and on their toes, Chappelle spends extra time performing observations and going over questions she knows the surveyor might ask the staff members.

“I get the staff members used to answering questions and putting them on the spot,” says Chappelle.

One staff member told Chappelle the exercise helped tremendously and that speaking with the surveyor was just like talking with her.

The staff members at Bothwell also received an 11-page packet that covers the policies and procedures within the lab.

“The staff members were required to read the packet and sign off on them to ensure they had read them,” says Chappelle.

In the packet, specific words and phrases are bolded and underlined to reiterate the importance of particular policies and procedures.

For example, staff members can find “in the presence of the patient” bolded and underlined, as well as “patient identification” and “quality control.”

Aside from receiving an RFI, McKeon and Chappelle feel the survey was a success.

“The surveyor thought some areas we did very well in,” says McKeon. “She commented on our recordkeeping and overall felt confident we were doing quality work.”

For other labs waiting to be surveyed, McKeon suggests paying attention and focusing on the statistics. “That was one thing the surveyor seemed to really focus on when we went through our inspection,” she says.

Chappelle encourages leadership to provide process updates to staff members because it helps them feel more comfortable with the processes and being put on the spot.

“The staff members handled this survey very well, and when they talk to the surveyor, I just tell them to picture me instead,” says Chappelle.