Every year, Crozer-Keystone’s pathology laboratories conduct over 2.5 million tests, yielding about 4 million results. In order to provide physicians and their patients with the highest quality testing possible, Crozer-Keystone’s laboratories submit to an inspection by a number of institutions.
Earlier this year, Crozer-Keystone’s pathology labs received reaccreditation from the College of American Pathologists (CAP). A team of 14 pathologists from non-CKHS hospitals arrived unannounced to conduct the three-day inspection of Crozer-Keystone’s labs. The inspection team scored the labs against a 10,000-item checklist, which is updated twice per year.
Every two years, visiting inspectors read laboratory materials such as procedure guidelines, maintenance and quality control records and case reports. They also observe laboratory activities — especially those with an immediate impact on patient care — and interview laboratory staff.
The results of the visit are then weighed. If any minor deficiencies are found (those that are not seriously detrimental to test results and do not pose a threat to the lab staff’s safety), the lab is notified so it can improve its operations. Such problems do not interfere with the lab receiving accreditation. If there are more serious problems, the lab must submit proof that they have been properly addressed before CAP grants accreditation.
In addition to these inspections, each lab conducts a self-inspection between CAP inspections. The CAP also sends unknown specimens to each lab for each test it conducts three or four times a year.
“The inspection is an increasingly rigorous examination. Historically, the College has focused on the quality of our product — test accuracy and data integrity — and the safety of those who produce the product. While the College continues to monitor those processes, they have broadened their scope to include how the Laboratory is involved in the processes of the hospital system. We are expected to be a proactive, integral component,” says Jeffrey Loose, M.D., chairman of the Department of Pathology at Taylor Hospital. “My Taylor managerial and technical colleagues and I look forward to maintaining and growing the relationships necessary for this to continue.”
In addition to CAP inspections, Crozer-Keystone’s labs also participate in Pennsylvania Department of Health, Joint Commission of the Accreditation of Healthcare Organizations, American Osteopathic Association and Food and Drug Administration testing.
“There has to be a safe environment in which the people work,” says Harvey Spector, M.D., chairman of the Department of Pathology at Crozer-Chester Medical Center. “We also have to make sure we have the best results we can for the patients and doctors.”
In addition to lab safety and procedures, the inspection team also checks to see how cohesive labs within a system are.
“Systems are rated based on congruity,” says Florence Norton, manager of Taylor Hospital’s lab. “Most of our policies and procedures apply system-wide and most of the records are kept at Crozer. That way, it takes less time for inspection.”
The pathology labs assist doctors in diagnosing and treating patients by examining specimens, such as blood samples and tissue slides. When a review of external symptoms is insufficient for diagnosis, lab tests of samples can reveal what is wrong.
“If there is something wrong with you, and nobody can figure out what it is, they’re going to cut off a piece of it and send it to me,” says Lawrence Matthews, M.D., chairman of the Department of Pathology at DCMH.
For more information about Crozer-Keystone Health System, visit www.crozer.org.