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Helpful MCN Healthcare Resources
Today's notice is the last in our series reviewing the Joint Commission's (TJC) changes to their Laboratory Accreditation Manual, effective July 15, 2015. StayAlert previously reviewed the changes made to the Document and Process Control Chapter (10-7-2014), Human Resources Chapter (10-13-14) and Transplant Safety and Environment of Care Chapters (12-4-14). Today's notice reviews some of the key revisions to the Quality System Assessment for Non-waived Testing (QSA) Chapter.
Summary of Key Revisions:
- The Clinical Laboratory shall have a system in place to evaluate the accuracy and reliability of results obtained for nonregulated analytes and regulated analytes that are not included in a formal proficiently testing program and for those regulated analytes for which compatible proficiency testing samples are not available.
- The addition of a note that clarifies that a laboratory director may delegate the responsibility for handling and testing proficiency testing samples, in writing, to a technical consultant meeting the qualifications of 42 CFR 493.1409 (for moderate-complexity testing) or technical supervisor meeting the qualifications of 42 CFR 493.1447 (for high-complexity testing).
- The addition of a note that clarifies that when using automated cell counters, calibration verification requirements are met if the laboratory follows manufacturer's instructions for instrument operation and the laboratory tests two levels of quality control materials each day of patient testing provided the laboratory's quality control criteria are met.
- After calibration, in order to verify that the calibration protocol was successful., the laboratory performs quality control testing before resuming patient testing.
- When evaluating noninstrument-based testing, laboratories are required to document both external and internal quality control results.
- The addition of a note that clarifies that when the screen and transfusion history for detection of unexpected antibodies is negative, the antiglobulin phase of testing is optional. Testing to detect ABO incompatibility (serologic or computer crossmatch) is required.
- A requirement that the expiration date of blood component products is changed to reflect that of an open system if an intact seal a closed system is not maintained during aliquot preparation.
- The laboratory establishes workload limits for staff who perform primary cytology screening and workload requirements apply to all cytotechnologists, pathologists, and pathology residents in the final year of training leading to board certification.
Included with today's notice are associated policies. Please see TJC's prepublication standards link, included below, for a complete list of changes and revisions to the laboratory standards.
In order to meet the requirements of the Joint Commission's (TJC) Disease Specific Care Advanced Certification in Heart Failure (ACHF), which was introduced in 2013, organizations must collect data for six mandatory inpatient measures as well as the two existing heart failure (HF) core measures.
In addition, TJC has seven outpatient measures that are designed to help organizations provide care for HF patients when they transition from inpatient to outpatient care. The seven outpatient measures are optional but TJC strongly encourages organizations to collect data on them if it is available.
The Joint Commission has posted ACHF performance measure implementation guides and the HF core measures on their website.Follow the link below for more information.
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MCN's NEW Ambulatory Surgical Center/Outpatient Surgery Department Policy and Procedure Manual is cross referenced to TJC standards, AAAHC standards and CMS regulations. Policies and procedures meet AORN and CDC recommendations and guidelines. This comprehensive reference guide has over 290 policies and procedures that are ready to customize to your organization. See also the Administrative Manual for Ambulatory Care Facilities and the Ambulatory Services EOC Manual.Read more »
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MCN's Post Anesthesia Care Policy and Procedure Manual is a comprehensive resource that covers the latest "hot topic" regulatory and patient safety issues that are relevant to PACU! This manual includes administrative, operational, functional and patient-centered policies and procedures. Policies and procedures are cross-referenced to CMS regulations, Joint Commission standards and NIAHO standards.Read more »