Cyprian Odeke

Cyprian Odeke runs quality control for the COBAS 8000 in the Chemistry Laboratory.

The Department of Pathology laboratories were recognized by surveyors from two accrediting bodies – The Joint Commission (TJC) and the American Society for Histocompatibility and Immunogenetics (ASHI) – for their extraordinary performance in quality and safety following two surveys in May.

The survey results are the latest in a long tradition of excellent marks from both entities. Particularly significant was the flawless report from the ASHI, which surveyed the Tissue Typing Histocompatibility Lab and concluded there were no findings to address – a rare outcome for an organization as large as BWH.

“Our staff’s commitment to service excellence, professionalism and team spirit came through loud and clear to the surveyors,” said Milenko Tanasijevic, MD, MBA, vice chair for Clinical Pathology and Quality. “They go above and beyond for every specimen and demonstrate their dedication to our patients every single day, regardless of whether a survey is occurring.”

During the four-day, unannounced TJC visit, which takes place every two years, surveyors evaluated compliance with laboratory standards in the labs, patient care areas, select on-site ambulatory practices and select off-site locations across BWH.

“The surveyors were so complimentary the whole time they were here. They commented on how incredibly professional and knowledgeable our staff are,” said Denise Fountain, MS, MT(ASCP)SBB, CQA(ASQ), director of Quality Assurance and Regulatory Compliance in Pathology.

Sara White

Sara White checks cell growth in a tissue culture on an inverted microscope in the Cytogenetics Tissue Culture Laboratory.

For the first time, TJC surveyors evaluated the labs using a new scoring methodology, The SAFER Matrix, which weighs instances of noncompliance by risk and magnitude. Surveyors identified a small number of findings to be addressed – fewer than most hospitals the size of BWH – and praised the staff for their professionalism, commitment and attention to detail. Since the completion of the survey, the BWH labs have addressed all findings from the report.

The ASHI survey, which also takes place every two years, praised the cutting-edge testing and highly advanced, specialized services provided by the Tissue Typing Histocompatibility Lab, Tanasijevic said.

“These successes are especially impressive given the pace of innovation in the field, and every BWHer should take pride in the outcomes of both surveys,” said Jeffrey Golden, MD, chair of Pathology.

“For example, five years ago, we rarely sequenced tumors. Now we look at the genome of most tumors to help inform how each patient should be treated,” Golden added. “When you factor in the regulatory changes that come with adoption of these new technologies, these surveys can be extremely challenging. But the remarkable commitment of our staff, no matter what challenges they face, ensure that we continue to be a high-quality, safe laboratory that provides the very best care for our patients.”

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