JCAHO Update for Infection Control

Lab an area of increasing interest in JCAHO surveys

Now linked to overall hospital accreditation

The Joint Commission on Accreditation of Healthcare Organizations has determined that the laboratory is an "essential service," meaning "failure in the laboratory extends to failure in the hospital," advises compliance consultant Dave Woodard, CIC, CLS, manager of Infection Control and Laboratory Services in Fountain Valley, CA. "That actually was published in [Joint Commission] Perspectives in October 2004," he points out. "It’s one of those kind of things that [ICPs] may not know. [The lab] is a hospitalwide issue," Woodard explains.

Clinical laboratories used to be surveyed under a different manual, but "what they are saying now is that the laboratory is an essential part of the hospital, and therefore, whatever they find in the lab overarches into the hospital as well," he adds.

A preliminary denial of accreditation (PDA) in the lab equates to a PDA for the hospital, says Woodard. Similarly, a conditional accreditation in the lab — if the hospital has an existing conditional survey — equates to a PDA. "There is much more at jeopardy now than before," he notes.

Of course, the lab always has had important infection control implications, but the Joint Commission’s new tracer survey methodology makes the connection all the more apparent. The tracer method involves detailed tracking of selected patients and/or clinical threads, so surveyors may chose, for example, to follow a phlebotomist on blood draws.

"We see them cite hospitals for failure to comply with isolation protocols," Woodard continues. "Because with the tracer methodology, they are out looking at practice. They are going to follow the phlebotomist to go get the blood. If the phlebotomists do not wash their hands, if they don’t abide by whatever isolation signs are on the door, if they haven’t been fit-tested for their N95 mask [for entering TB patients rooms] — all of those things are then deficiencies in the infection control program."

Surveyors will check also to determine if the lab protocols for blood and bone banks are in line with national laboratory guidelines.

Point-of-care testing is another area of major interest. ICPs should ensure that quality control measures are in place for such testing, and lab diagnostic media are used according to guidelines by the Clinical and Laboratory Standards Institute (www.clsi.org/).

By the same token, if the lab does "wet mounts" for trichomonas, make sure you have a Clinical Laboratory Improvement Amendments certificate in proficiency testing for parasitology, Woodard says. The Joint Commission currently is being very precise in evaluating each of the elements of lab performance, he advises. "What the Joint Commission is doing in the laboratory is just like they did in the hospitals about a year ago," Woodard notes.

"The have defined elements of performance. It’s not a bad thing, but there is not a lot of wiggle room there. I think it is important that infection control does include the lab in its program," he adds. "Obviously, it is a high-risk area to employees and there are certainly issues that we in infection control do that are laboratory-dependent, such as all of our microbiology [surveillance]," explains Woodard.