Practice in TAMC lab
to be used as national model
PRESQUE ISLE — A recent routine inspection of the TAMC laboratory led to an unexpected opportunity for the hospital to lead by example after the accrediting agency responsible for conducting the inspections asked to use a TAMC-employee designed checklist as a model for laboratories across the nation.
Photo courtesy of TAMC
JAN McCUE, TAMC’s lead lab technologist in hematology and transfusion services, holds a copy of the checklist she developed that has been adopted by the College of American Pathologists (CAP) as a national model. David Craig, TAMC manager of laboratory services, holds the framed accreditation certificate presented by CAP to TAMC. It was during a recent routine inspection of the laboratory at TAMC by CAP that McCue’s checklist was seen by a reviewer with the accrediting agency responsible for conducting the inspections. The reviewer shared the checklist with colleagues at CAP who, in turn, contacted McCue asking to use the document she created to share with hospitals nationwide as an example of a “best practice.”
Dr. John C. Tewksbury recently received notification that TAMC’s main laboratory had passed its biennial inspection, successfully earning its accreditation for the next two years.
The College of American Pathologists (CAP) performs an unannounced on-site inspection at TAMC every two years as part of the accreditation process. To earn the accreditation, the lab at TAMC must comply with stringent guidelines and standards that CAP has established. In fact, the CAP Laboratory Accreditation Program is recognized as one of the most stringent in the industry, according to David Craig, TAMC manager of laboratory services.
During the accreditation process, designed to ensure the highest standard of care for all laboratory patients, inspectors examine the laboratory’s records and quality control of procedures for the preceding two years. CAP inspectors also examine laboratory staff qualifications, equipment, facilities, safety programs and records, and overall management.
“Each department within the lab works on a daily basis to assure that we meet the accreditation standards,” said Craig. “Medical laboratories perform a variety of services to patients, including testing in microbiology, hematology, chemistry, transfusion services and anatomic pathology. It is vital that the personnel in the lab demonstrate a high level of competency in performing their jobs. In fact, one thing labs are required to do to earn and maintain their accreditation is to document this competency. Lab technologists need to show competency in all areas that they perform testing in.”
The six elements to meeting the competency include direct observation of routine patient test performance, monitoring of the recording and reporting of test results, review of intermediate test results or worksheets, direct observation of performance of instrument maintenance and function checks, assessment of test performance through testing previously analyzed specimens, and evaluation of problem solving skills.
Each department within the lab is charged with documenting these competencies, and each department develops their own method of documentation. It was Jan McCue, lead tech in hematology and transfusion services, who developed a checklist that not only met all of the documenting needs that CAP required, but prompted them to seek her out. Craig received a phone call from a CAP representative asking that the other lab departments begin to use the same form and also if they could have permission from TAMC to use the form as a model for other laboratories across the nation who might need a better method for documenting competency in their personnel.
Craig said the CAP representative stated that “many labs struggle with this portion of accreditation and that CAP would like to use TAMC Lab’s competency worksheet as an example for these labs to improve their competency assessment.”
“I wanted to develop a simple checklist that would incorporate all the essential elements of competency evaluations that is required by the College of American Pathologists,” said McCue. “I needed something what would be user-friendly and easy to comprehend for annually evaluating technologist competencies. The checklist has worked well for several years and I now use it for both hematology and transfusion services.”
“Jan is very much on top of ensuring that she meets each standard that CAP requires. I think she just looked at the problem of documenting competency properly and arrived at this solution,” said Craig. “The six elements and the documentation necessary for each element were all included in one document. Before we lacked one unified document.”
Based on CAP’s suggestion, TAMC incorporated McCue’s checklist into all of the lab departments, as labs across the country may be doing soon.
“I feel very humbled and surprised that my checklist has been considered a national model by CAP,” said McCue.
