CAP vs TJC
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Here's a fun topic idea:
Citations you've gotten that maybe the other organization isn't citing.
Especially in POC, there seem to be some really big differences in what CAP and TJC are focused on.
TJC citations (does CAP focus on these?):
1. Accu Chek meter disinfection (first wet time requirements, then number of vertical and horizontal wipes as directed by the mfr in their several hundred-page glucometer manual)
2. Individually labelled ACT cuvettes with new expiration (not on the whole box)
3. Humidity tracking in storage locations when prescribed by mfr (think glucometer strips!)
4. Direct patient observation in addition to annual prev/blind/prof performance (actual sample collection from a patient through resulting)
I'm sure I'll think of more.
Citations you've gotten that maybe the other organization isn't citing.
Especially in POC, there seem to be some really big differences in what CAP and TJC are focused on.
TJC citations (does CAP focus on these?):
1. Accu Chek meter disinfection (first wet time requirements, then number of vertical and horizontal wipes as directed by the mfr in their several hundred-page glucometer manual)
2. Individually labelled ACT cuvettes with new expiration (not on the whole box)
3. Humidity tracking in storage locations when prescribed by mfr (think glucometer strips!)
4. Direct patient observation in addition to annual prev/blind/prof performance (actual sample collection from a patient through resulting)
I'm sure I'll think of more.
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All 4 were brought to our attention by the Inspectors over the years.
#1 – we were able to show our education fliers regarding dwell time – not cited but we did a lot to reeducation.
#2 – we always label it when taken out of refrigeration not an issue but was discussed extensively on the WHY?
#3 – We have to install TEMPTRACK on all storage location that were discovered so that we do not get cited – did it during inspection.
#4 - extensive discussion on what it means to do “Direct Observation” with the inspector to prove what our process is on meeting this competency documentation requirements.
Sincerely,
Alma
“Far and away the best prize that life offers is the CHANCE to work hard at work worth doing” – Theodore Roosevelt
Alma Calzado-Knudson, MBA, CLS, MT (ASCPi & AMT)
Manager, Lab Quality and Point of Care Testing
Student Education Coordinator
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“Together you and I will Each Accomplish More as we WORK towards achieving a common goal – Patient Safety and Satisfaction”
This year I have gone through BOTH TJC and CAP inspections a few months apart.
Both wanted to hear about the cleaning and disinfection of the Accuchek glucometers. They wanted to hear the horizontal/vertical cleaning steps exactly as described in the operator manual.
All cartridges should be individually dated (this goes for Hemochron, iSTAT, ect.) Both sets of inspectors wanted to see this in my OR and Cath Lab areas.
I was asking for room temperature and humidity tracking for several POC testing supplies. Luckily, we have paper documentation on all units that perform POC testing. CAP wanted to see areas that are closed on weekends with min/max temperature documentation as well.
As per direct patient observation, I have created an assessor delegation for that is signed by my medical director to ensure that the personnel signing off competencies is aware of and understands their required duties. We use blind samples (QC) with known values for competency assessment.
TJC considers cartridges as the analyzers were all the reactions happen and the i-STAT as a reader, so running electronic simulators between i-STATs are considered equivalent, where else CAP always considers Cartridges and the i-STAT analyzer as a "test system" and requires liquid QCs to compares i-STATs. This is just my observation and thought.
2. TJC also asked nursing in every one of our facilities during the last round of inspections to demonstrate proper cleaning of glucometers....CAP has never asked for that either.
3. On the flip side, CAP looked at the expiration dates of our glucometer batteries...TJC has never done that.
@Kayla... oh man those are great. I love hearing some of these.
Thank you!