Scope of Service. Department Mission

Transcription

1 Scope of Service Department Mission Scope of Services Provided The Department of Laboratory Services provides a wide array of testing and other services to Memorial Health System s patients, and to other patients and organizations in support of the System s mission, operating objectives and strategic priorities. The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-mhs healthcare providers. 1) Clinical laboratory services, including routine and stat specimen collection, blood gas analysis, blood banking, chemistry, coagulation testing, endocrinology, hematology, bone marrow aspirations, immunohematology, immunology, microbiology, molecular diagnostics, mycobacteriology, mycology, parasitology, serology, therapeutic drug monitoring/ toxicology, urinalysis, electrophoresis, virology and clinical pathology consultation. 2) Anatomic pathology services, including interpretation and diagnoses on surgical and other specimens submitted for pathologist review, autopsies, cytology, Fluorescence in situ hybridization (FISH), flow cytometry interpretations, histology, immunohistochemistry, fine needle aspirations, and pathologist-performed cortisol stimulation injection testing. Additionally, Frozen Section service is available to support procedures performed at Printers Park Medical Plaza, Memorial Hospital Central and Memorial Hospital North. 3) Other Laboratory services a. Management and oversight of Point of Care Testing (POCT) Program b. Consultation services to off-site physician office laboratories c. Therapeutic phlebotomies which are performed with a physician s order and treatment plan. Out-patients are drawn by appointment at both the North and Main campus; in-patient phlebotomies are available upon request. Therapeutic apheresis is not available for Memorial Health System patients at this time. 4) Blood/Components Available from Transfusion Services (products provided primarily via a partnership with Bonfils Blood Center) a. Leukoreduced Red Blood Cells b. Fresh Frozen Plasma, thawed c. FP24 d. Platelets, apheresis, prestorage leukocyte reduced e. Cryoprecipitate f. Pediatric aliquots (red cell, FFP, Cryo, Platelets) g. Washed and/or deglycerolyzed Red Blood Cells h. Cryo-poor plasma, pooled i. Rh Immune Globulin

2 j. Irradiated cellular products when ordered or as indicated* k. Sickle cell patients treated at Memorial are enrolled in the Bonfils Blood Center (BBC) Sickle Cell Program and are provided with antigen matched red blood cell units. Other blood products are ordered from BBC as needed. BBC also serves as the primary reference lab for antibody identification problems and access to the rare donor file. *Not immediately available at North; testing performed at Central. Hours of Operation Central and North Clinical Laboratories Operate 24 hours per day, 7 days per week, 365 days per year. Histology: M-F Sat Cytology: M-F Outpatient Phlebotomy: Central and North: M-F , Sat Briargate Medical Center: M-F Printers Park Medical Plaza: M-F Therapeutic Phlebotomy: Central: M, W, F , by appointment North: T, Th: , by appointment Number of Beds Population Served N/A Memorial Health System laboratories serve all age groups seen in the inpatient, outpatient and clinic populations, including premature babies, neonates, infants, children, adolescents, adults and geriatric patients. 1) In addition, we provide services tailored to special groups such as routine and high-risk obstetric patients, mentally and physically handicapped patients, pediatric and adult Oncology patients, combative and abusive patients, non-english speaking patients, patients with religious restrictions and bereaved family members. 2) In situations where handling and/or testing is specific and unique to a patient population, the Laboratory provides specialized training to ensure that the patient s individual needs are met with dignity, professionalism and respect. 3) Where issues of access occur, the laboratories attempt to make reasonable arrangements to accommodate the patient, caregiver, or provider. Type of Services Clinical Laboratory Testing and Surgical/Anatomic Pathology Services

3 Staffing Plan Laboratory employees work assigned shifts in specific laboratory areas as scheduled by section or shift supervisors. Appropriate staffing levels for each section in the Department are established utilizing established productivity standards developed in conjuction with the MHS Finance department. These standards form the basis for approved overall staffing levels and allocations to specific laboratory areas. Ongoing changes in test volumes and testing services are used to flex the department s staffing levels to adjust to changes in work activity. Staffing is sufficient to assure that assigned functions are completed, patient and employee safety is maintained and the integrity of results is maintained. 1) Professional Staff a. Laboratory professional staff (medical technologists, medical laboratory technicians, cytotechnologists, histologic technologists, histologic technicians) are board certified and work in specific technical sections, or as generalists who can be assigned to work in several different sections. Staffing levels vary based on anticipated workload, and scheduled and unscheduled absences. b. In the event of unforeseen absences, unusual workload fluctuations, or method or equipment failures, testing may be deferred or sent out to avoid unacceptable delays in testing. 2) Support Staff a. Histology Laboratory Assistants accurately and efficiently receives, accessions, bills, prepares specimens for diagnosis, and assists in frozen sections and morgue, as well as performing maintenance duties, specimen tissue disposable, and filing. b. Cytology Laboratory Assistants accurately and efficiently performs cytopreparatory tasks to include technical assistance on fine needle aspiration procedures, as well as, performing purchasing, requisition, inventory, and maintenance of section supplies and equipment. c. Phlebotomists/Phlebotomy Technicians provide a variety of support services for the Department, including specimen collection, accessioning, specimen processing, storage and retrieval, courier sample registration, charting, communications, FSBS, Sweat Tests, and managing the Send-Out (reference lab) program. New employees may start work in Blood Drawing and gradually expand to other activities handled by this section, or may be hired as a best fit to work in one of the specific areas. This section works all three shifts and staff may move from one shift to another and from one campus to another as needed to provide coverage. d. Customer Service Representatives working in the Clinical Lab and Pathology Call Center provide professional services through electronic, telephone, and personal interactions: answering calls, routing reports, calling results, scheduling procedures, offering informal instruction, and troubleshooting issues.

4 Service Providers Job Title Minimum Education Required Certification / Registration / Licensure Medical Director MD Board Certified AP/CP Pathologist MD Board Certified AP/CP Pathologist Assistant Master s PA(ASCP) Administrative Director Master s MT(ASCP) or CLS (NCA) Lab Manager Medical Technologist Supervisor / Senior Medical Technologist (I and II) Medical Laboratory Technician Cytotechnologist, Supervisor / Senior Cytotechnologist Cytology Lab Assistant Histotechnologist Supervisor / Senior Histotechnologist Histology Lab Assistant Degree Diploma plus some college or MT(ASCP) or MT(ASCP) or MT(ASCP) or MLT(ASCP) CT(ASCP), CMIAC CT(ASCP), CMIAC HT(ASCP) or HTL(ASCP) HT(ASCP) or HTL(ASCP)

5 Supervisor (Inpatient and Outpatient) Phlebotomy Technician II Phlebotomy Technician I Phlebotomist Customer Service Supervisor Customer Service Representative Lab Informatics (LIS) Database Coordinator Lab Informatics (LIS) Support Specialist in healthcare or MLT (ASCP or AMT) plus some professional training in medical area of study or MLT (ASCP or AMT) or in experience and training MT(ASCP) or Lab Compliance Liaison Lab Outreach Relations Representative

6 Lab Safety Specialist Lab Quality and Education Specialist Administrative Support MT (ASCP), MLT(ASCP), PA(ASCP), HLT(ASCP), HT(ASCP) or MT(ASCP) Department Standards/Practice Guidelines Communication 1) The laboratories operate within the regulatory requirements and/or accreditation standards of the following organizations: a. CMS, Clinical Laboratory Improvement Act (CLIA) b. College of American Pathologist (CAP) c. The Joint Commission d. American Association of Blood Banks (AABB) e. Food and Drug Administration (FDA) f. Clinical Laboratory Standards Institute (CLSI) 2) Departmental policies, processes and procedures are developed based on needs revealed by patient demographics, advances in the industry, changes in regulations, inspection reports, and deficiencies or inadequacies identified in current processes. Audits and systems checks are in place or are being developed as a means to evaluate and modify current processes. A standardized process is in place for implementation of new policies and procedures. 1) Communication systems within the Laboratory sections include: a. Overhead paging b. Cisco phones for pathologists c. Cisco phones for administrative charge, 24/7, x52586 d. Lotus Notes e. MHS leadership forums 2) Formal Meetings - Meeting minutes document formal meetings held in the Department. Distribution of minutes may include , availability of an electronic copy and posting in the section and/or in the Laboratory Lounge. a. Monthly Laboratory Leadership meetings b. Ad hoc work groups c. Pathology section meetings d. Laboratory Quality Committee meetings e. Laboratory Safety Committee meetings f. Section meetings g. Lab Management meetings