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Discussing Issues and Solutions to the
Most Common CAP & JCAHO
SOUTHERN
CALIFORNIA POC USERS GROUP MEETING
Tuesday
– February 27, 2001
Minutes
of Meeting
A.
Open Group Discussion of Issues and Solutions for the Common CAP and
JCAHO Point-of-Care Deficiencies
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POC
Institution
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Inspecting
Agency |
Deficiency/Recommendation/Comments |
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St.
John’s Hospital
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JCAHO
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1.
JCAHO gave emphasis on: where the POC testing are performed,
who performs the test, critical result parameters and physician’s
response to critical results.
2.
Waived testing performed in facility is inspected by JCAHO and
moderate complexity test is under the Lab’s CAP license.
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CAP
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1.
Inadequate ACT documentation.
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Veteran’s
|
CAP
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1.
No deficiency.
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Good
Samaritan Hospital
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JCAHO
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2.
Emphasis on documentation, RN in charge and whom to call if
glucose meter is non-operational, screening vs. definitive, testing
areas.
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CAP
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1.
No deficiency on glucose meters.
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UCLA
– Westwood Campus
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JCAHO
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1.
Facility hired consultants to assist them for the JCAHO
inspection.
2.
Emphasis was given on documentation, open dates, critical
limits, corrective action, education (which was attained by holding
Skills Lab annually and having RN Trainers) and monitoring of QC
(Monthly report generated by POCT Coordinator).
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Peggy
Tessier, UCLA-WW (shared previous experience in a POL)
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DHS
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1.
Emphasis on QC, education, competency, supervision of
non-licensed personnel and rounds of different laboratory sites.
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St.
Joseph’s Hospital
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JCAHO
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1.
Licensed vs. non-licensed personnel. Non-licensed personnel are
not allowed to perform test that requires interpretation.
2.
ABG: screening vs. diagnostic
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Queen
of Angels
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CAP
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1.
Deficiency: did not establish acceptable range on QC (on
glucose meters). Group suggested to validate manufacturer’s QC range
by performing test on different meters whenever there’s a new lot
and new shipment, sequester lot and have pharmacy notify the lab
receipt of reagents.
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POC
Institution
|
Inspecting
Agency |
Deficiency/Recommendation/Comments
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Torrance
Memorial Medical Center
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JCAHO
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1.
POC testing under CLIA license.
2.
No deficiency.
3.
Next inspection in two years and will involve more nursing
participation.
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Children’s
Hospital
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JCAHO
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1.
Cardiology Dept – ACT Proficiency Testing
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Cedars-Sinai
Medical Center
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JCAHO
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1.
Emphasis was where records were kept, which is in the lab.
2.
Just switched to CAP the year before.
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Kaiser
Permanente
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JCAHO
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1.
Each area has own CLIA license.
2.
Performs PPM and moderate complexity testing.
3.
Emphasis was on the corrective action taken on unsatisfactory
proficiency testing results, annual competency, training and
procedures.
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B.
Comments and Suggestions from the group on how to be prepared for the
next inspection:
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Define
POC test whether screening or diagnostic.
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Refer
to JCAHO Handbook for POCT guidelines: POCT – Quality Point of Care
Testing.
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Perform
correlation between instruments (including laboratory instrument)
bi-annually and establish acceptable limits using CAP survey samples and
patient samples.
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Monitor
and document instrument maintenance and QC performance.
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Review
patient results on a routine basis.
C.
Topics for Next Meeting:
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Data
Management
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Personnel
Regulation
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Bring
monthly report generated for nurse managers
D.
Next Meeting
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Date:
June 19, 2001
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Time:
12:00 p.m. – 1:30 p.m.
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Where:
6E Classroom (67-231 CHS) UCLA-Westwood
Space
for the June 19th meeting is limited—Please RSVP to:
Vida
Montgomery, Point of Care Testing Coordinator, UCLA MC at 310-825-6239 or Vmontgomery@mednet.ucla.edu
Directions
From
the 405 Freeway, Exit Wilshire EAST, to Westwood NORTH or Left, to
LeConte
EAST or Right, to Tiverton NORTH or Left, to Parking Kiosk, ask for CHS
parking,
$6.00.
From Parking Structure enter “Hospital
Main Entrance” Use EAST Elevator to 6th Floor, Room 67-231
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