From left: Marcia Niland, Wendy Fuld and Anne McCue at an ice-cream social celebrating a successful Joint Commission survey

Last month, representatives from The Joint Commission witnessed firsthand BWH’s leadership in promoting excellence in the quality and safety of patient care during their survey of BWH’s clinical Pathology labs.

“It was very gratifying to hear the inspectors compliment us on having outstanding clinical labs with many best practices,” said Jeffrey Golden, MD, chair of the Department of Pathology. “I am extremely proud of our incredibly strong team and the care we provide to our BWH patients every day.”

During the four-day unannounced visit, which takes place every two years, surveyors from TJC evaluated compliance with laboratory standards in the labs, patient care areas, select on-site ambulatory practices and select off-site locations across BWH, including Anatomic Pathology, ambulatory labs, Blood Bank, Chemistry and various patient nursing units. In addition, the surveyors also focused on TJC National Patient Safety Goals, infection control and emergency preparedness in these locations.

Surveyors used the tracer methodology, a means of evaluation in which they select a patient and use that individual’s record as a roadmap to assess an organization’s compliance with certain standards and its systems of care and services.

“The excellent marks received during this survey epitomize the Department of Pathology’s relentless pursuit of service excellence,” said Milenko Tanasijevic, MD, MBA, director of Pathology’s Clinical Laboratories Division, noting that for the last two decades, Pathology has received high marks from TJC. “We strive continually to provide high-quality, timely laboratory testing to our patients and clinicians.”

Even more impressive, Tanasijevic said, was Pathology staff’s ability to accomplish a host of service advancements while facing the unprecedented challenge of having only 18 months to implement a new laboratory information system and interface it with Partners eCare, BWH’s Epic-based electronic health record system, which launched last year.

There are a few findings that will need to be addressed, mostly related to Epic. For example, there were locations where the names and addresses of the test-performing labs, a requirement on all reports, were not present. Golden said BWH is committed to correcting the findings in an effort to remain at the very highest standard.

“There are always opportunities to do better, and our staff is firmly committed to ongoing quality improvement,” Tanasijevic said.

This survey is particularly notable because it affects almost every department in the hospital, as clinical labs are dispersed across BWH, said Pamela Wakefield, compliance officer for the Clinical Laboratories.

“This was a massive team effort, and we didn’t miss a beat in terms of our preparedness. The credit goes to the frontline staff who made this survey a success. They make us very proud,” Wakefield said.