Joint Commission news
Laboratory surveys completed at EUH/EUOSH, EUHM and WWGH
New Universal Protocol Policy and implementation of Revised Universal Protocol Policy
The biennial survey of the laboratory program at all Emory Healthcare (EHC) facilities is under way, with three of four expected onsite surveys completed in May and June. Emory University Hospital Midtown (EUHM), Wesley Woods Geriatric Hospital (WWGH) and Emory University Hospital/Emory University Orthopaedics & Spine Hospital (EUOSH), were reviewed by the single surveyor on May 24 -25, May 26 and June 7-9, respectively, on compliance to The Joint Commission’s (TJC) laboratory standards. Overall results were very positive. However, a need to improve compliance in a few areas specific to each hospital was noted. Identified issues will be addressed by involved staff over the next few weeks, with final reports of compliance action forwarded to TJC by required deadlines. The surveyor praised the lab programs, and noted involved staff was “clearly focused on providing safe and effective patient care,” while being “extremely open to constructive feedback on process improvement.” Thanks to all physicians and staff whose efforts ensured our hospital facilities were survey-ready. There is just one TJC lab survey remaining this year involving The Emory Clinic, due for completion by September 19, 2010.
The recently revised EHC “Universal Protocol for Prevention of Wrong Site, Patient or Procedure Surgery/Invasive Procedure” was successfully implemented across the enterprise on June 1, 2010. For those who would like to review the policy, visit the EHC intranet and select “Policies & Procedures for Emory Healthcare”.
If you wish to view supporting educational material specific to recent changes, visit TJC section of the EHC intranet (under the Clinical Resources tab) and select Staff Education Materials.
For questions or further information about TJC issues, please contact Amy Nally, RN, MS, CIC, CPHQ, Director, Clinical Performance Improvement – Accreditation Support Services, Office of Quality at 404-712-4545 or amy.nally@emoryhealthcare.org.
