OK, everybody crack open your JCAHO requirement manuals... We are a MOHS lab and were surveyed by Joint Commission about 2 months ago. During the survey, we were cited because we only retain our physical tissue specimens for 24 hours, as they remain fresh and are not fixed. We throw the tissue the following afternoon vs. retaining for the "1 week after microscopic sections are examined and reports are reviewed and signed." (Standard #QC.2.120) Has anyone else (specifically a Mohs lab) been cited for this? We are currently trying to appeal, but have been denied so far. I am having a teleconference with the JCAHO powers that be to try and get the appeal going again, but I'm not the lawyer type. The letter states that their interpretation is that even if the tissue is not regarded as 'gross' tissue, any 'useable' tissue must be retained for a minimum of a week after the case is signed off on.I am thinking on focusing on the 'useable' bit as related to diagnostic value of delayed retained fresh tissue processing i.e. freeze artifact, tissue degredation, inability to perform ancillary testing, etc. Also, what is the definition of 'reviewed and signed reports'? Does this mean when the case is finalized, or just the tissue sections in question? We sometimes have patients that go a month + between Mohs procedures on the same positive lesion. We will probably have to get a -80 freezer for this if the appeal doesn't go through. Not to mention the fact that some of our cases are not resolved for months. We would have constantly search when cases are finalized to know when we can dispose of the tissue. FYI, the letter also states that the JCAHO standard is more stringent than the CLIA standard, so I'm not even really going to use it in arguments. HELP! Claire Ingles UW Hospital & Clinics Madison WI
_______________________________________________ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
