City of Hope’s Pathology and Histocompatibility (HLA) laboratory services received exceptionally high marks during a recent surprise inspection by the College of American Pathologists on April 30, officials said.
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The accreditation inspection surveys earned positive comments and included only minor findings.
“We are very proud of the laboratory staff who interacted directly with the surveyors, as well as the management team and physicians who guided the preparation for the survey,” said Elizabeth Dunne, medical center executive officer.
The inspection encompassed several Division of Pathology departments, including Anatomic Pathology, Clinical Pathology and Transfusion Medicine, as well as the Diagnostic Molecular Pathology Laboratory.
“The HLA Laboratory and the Diagnostic Molecular Pathology Laboratory had no
citations whatsoever,” said Lawrence M. Weiss, M.D., chair of the Division of Pathology, “while the other areas had what I would describe as minor deficiencies.”
The Diagnostic Molecular Pathology Laboratory, in particular, improved its standing
significantly, according to Weiss. “We’re very pleased,” he said.
David Senitzer, Ph.D., director of the HLA Laboratory, noted the HLA lab has never received any survey citations from the College of American Pathologists, or CAP. He credits Laima Gaidulis, HLA Laboratory supervisor, with ensuring the lab remains compliant. “We did very well; our record remains unblemished,” he said.
According to Dunne, the lead surveyor commended each of the laboratory programs and City of Hope’s commitment to quality patient care. The surveyors also commended City of Hope’s policy of linking online department policies and procedures with the CAP survey checklist, she said.
CAP develops tailored checklists of accreditation standards based on individual laboratory size and scope and posts them on their Web site so organizations such as City of Hope may reference them.
Dunne noted that CAP inspectors said they learned several best practices from City of Hope, which they will use with their own teams.
Twenty inspectors surveyed the institution and spoke with City of Hope staff members, said Weiss, who especially credited John Palmer, director of pathology, and Kristina Johnson, system coordinator and clerical manager in the Department of Anatomic Pathology, for their efforts preparing City of Hope for the survey.
The on-site inspection, part of the CAP biennial accreditation program, which is recognized by the Joint Commission, came unannounced, mirroring the Joint Commission policy. The Joint Commission has conducted all regular accreditation surveys without advance notice since 2006.
“This time they came about five months earlier than usual, and despite that, we did very well,” Palmer said. “Everyone is doing the right thing every day to make sure the labs are in top shape. We don’t cram for inspections, in other words.”
Johnson admitted the surprise visits can be stressful, but “even so, we were ready, and our team did an extraordinary job.” CAP accredits more than 6,000 laboratories and offers proficiency testing programs to 23,000 enrolled laboratories. It serves nearly 16,000 physician members and the laboratory community.