Becky Garrison makes some very valid and interesting points below....
First of all, the point about what a "critical test" is, as defined by JCHAO. She is correct, in that these are tests defined by the individual institution in policy, but not by JCAHO. Second, the item (ANP.11820) on the CAP checklist concerning turnaround time of intraoperative frozen sections reads as follows: The institution must "periodically" evaluate TAT and document reasons for delay BUT only if 90% of FS are not completed within 20 minutes. ANP.11820 Phase 1 Does the laboratory periodically evaluate turnaround time for intraoperative frozen sections? NOTE: If 90% of frozen sections are not completed within 20 minutes, the laboratory must document evaluation of the reason(s) for the delay. This turnaround time is intended to apply to the typical single frozen section. In cases where there are multiple sequential frozen sections required on a single specimen (e.g., resection margins), or in cases where additional studies such as radiographic correlation are required, longer turnaround times may be expected. COMMENTARY: N/A REFERENCE: Novis DA, Zarbo RJ. Interinstitutional comparison of frozen section turnaround time. A College of American Pathologists Q-Probes study of 32,868 frozen sections in 700 hospitals. Arch Pathol Lab Med. 1997;121:559-567. Robert L. Lott, HTL(ASCP) / Manager, Anatomic Pathology Trinity Medical Center/ LabFirst/ 800 Montclair Road / Birmingham, AL 35213/ 205-592-5387 Message: 19 Date: Thu, 25 Jun 2009 10:49:43 -0400 From: "Garrison, Becky" <becky.garri...@jax.ufl.edu> Subject: RE: [Histonet] Re: tracking turnaround time of intraoperativeconsultations To: "Della Speranza, Vinnie" <del...@musc.edu>, "Robert Richmond" <rsrichm...@gmail.com>, <histonet@lists.utsouthwestern.edu> Message-ID: <b3ca1baf6c5e4541867e4e79ad2412e003c29...@jaxmail.umc.ufl.edu> Content-Type: text/plain; charset="us-ascii" Sorry I did not respond yesterday. The reason we just started measuring order to sign out for frozens was also prompted by preparation for our next JCAHO inspection. However, there is this distinction. The Joint Commission does not define a frozen as a critical test. The designation of critical test is left up to the individual institution. However, once your institution defines the frozen as a critical test, (indicated somewhere in a policy), you must conform to JCAHO guidelines for critical tests. And apparently this is the buzz with JCAHO watchers right now. Here we designate the IntraOp consultations for frozens (not gross only or Touch prep) and IntraOp PTH (Clinical test) as a critical tests and have started tracking order to sign out. Order time is the time the surgeon indicates 'send this to pathology' not when pathology receives the specimen. We are somewhat in uncharted waters as there is no national standard that defines target time from order to sign out. We set a 40 minute time (20-OR to Path and 20-path to completed frozen). I campaigned against a 30 minute total time (15 each) because we do have some frozens that do take over 15 minutes and this was an absolute value (unlike the CAP goal of 90% within 20 minutes). Our approach is to monitor, evaluate the data we retrieve. There will certainly be adjustments made to target time and how and what we monitor. The data collection raises more questions: how do you come up with meaningful data for multiple specimens on a single case; multiple frozens (different patients) received together or before we are finished with the first patient's frozen). This is one of those ideas that sounds good in theory but presents some challenges in execution. But it is a valid process to monitor as we periodically have surgeons complain of the time they are waiting for frozen results. This is really a joint quality management review which involves multiple departments (OR and Pathology) and how we make it better for the patient. Becky Garrison Pathology Supervisor Shands Jacksonville Jacksonville, FL 32209 904-244-6237 -------------------------------------------------------------------------- Disclaimer: This electronic message may contain information that is Proprietary, Confidential, or legally privileged or protected. It is intended only for the use of the individual(s) and entity named in the message. If you are not an intended recipient of this message, please notify the sender immediately and delete the material from your computer. Do not deliver, distribute or copy this message and do not disclose its contents or take any action in reliance on the information it contains. _______________________________________________ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet