Utilization of the Northwell Health Laboratories Consulting Team to Ensure High Quality and Inspection Readiness in the NY Metropolitan Area

• Published in: American journal of clinical pathology Vol. 150; no. suppl_1; p. S121
• Main Authors: Nevins, Kyle, Hirsch, Roberta, Maher, Kathleen, Poczter, Hannah
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 21.09.2018
• Subjects: Hospitals; Laboratories; Tracers
• ISSN: 0002-9173; 1943-7722
• DOI: 10.1093/ajcp/aqy100.290

Abstract Objectives Northwell Health is one of the largest nonprofit health systems within the New York metropolitan area, providing laboratory services to over 20 hospitals and 500+ physician offices. Each laboratory is subject to regulatory agency inspections such as CAP, NYSDOH, and JCAHO. To ensure laboratory inspection readiness and maintain the highest level of quality, Northwell has formed a consulting team to efficiently assess the overall quality of services. Methods An audit schedule is made based on each location’s inspection window. Audits are completed within 1 day to minimize disruption to the laboratory, with follow-up audits scheduled as needed. Patient tracers are utilized to review all phases of the laboratory process. Staff are verbally notified of findings throughout the audit, with a formal written report following. Findings are used to identify systemic issues and benchmark best practices. Guidelines are provided for proper follow-up of deficiencies and/or quality issues. Conclusion In 2017, a total of 15 Northwell system laboratories were audited and 4 audits performed as consultants for non-Northwell laboratories. On average, our team identified 50 findings during our internal audits and 75 such findings at the non-Northwell laboratories. Comparing the 2017 regulatory inspection results to 2015, we found that 68.8% of audited sites had a decrease in their total deficiencies, with an overall 33.5% reduction in the total number of deficiencies received system-wide after implementation of the consulting team. Outside hospitals that utilized our services showed an average reduction of 66.2% in the total number of deficiencies received. Due to the proven value of our team, we will continue to expand our scope while focusing on implementation and sustainment of corrective actions. To increase our efficiency and expand the team, we are creating a training program to further guide our laboratories in the regulatory standards and methods for satisfying these requirements.