Excellent Reviews for GRMC Lab

The laboratory at Great River Medical Center in Blytheville recently 
got an excellent review from the Joint Commission on Accreditation of 
Healthcare Organizations, which will report their good findings to 
the state health department.
Mike Stallings, Great River Medical Center laboratory director, said 
the Joint Commission on Accreditation of Healthcare Organizations is 
an accreditation agency for hospitals.
"We pay them to do this," Stallings said. "They come in and evaluate 
every aspect of your operation and tell you what you are doing wrong. 
They give a report to our state health department, and if Joint 
Commission on Accreditation of Healthcare Organizations sees you are 
not doing something right they will make recommendations."
The survey, which was conducted June 15 and 16, was unannounced. 
Stallings explained that when the state health department conducted 
the surveys they knew exactly what day the evaluators would be there 
and the state came in automatically about every two years.
"But they don't do that if you are accredited by the Joint 
Commission on Accreditation of Healthcare Organizations," Stallings 
said. "I think Joint Commission on Accreditation of Healthcare 
Organizations is a little more strenuous than state health is. We 
don't even know that morning when they are coming. The let us know 
one hour before they are here. There is not much you can change in an 
hour and that is the reason behind it."
Stallings said the surveyors do more than just walk through and look 
at machinery.
"One of the first things they do is review or grade you on various 
things you do such as proficiency testing," Stallings said. "When we 
do proficiency testing a company will send us a blind sample and we 
run tests and give them an answer. They grade us and give us a 
percentage. If you flunk two in a row you can't run that test 
anymore. Thank goodness we have never done that. There is a lot more 
behind this than just checking machinery."
Stallings said the surveyor also looks at the quality controls in 
the lab. He said each test has a quality control associated with it 
and most have two controls.
"They (the surveyors) go over every book we have, and they do this 
every two years," Stallings said. "So when they come back after two 
years they look at two years worth of work. They don't just look at 
records from today. It is a nerve-racking process. People ask, 'why 
do you do this?' Well, the reason you do this is because you want 
someone to come in so we can ask if we are doing things like we are 
supposed to and let them make recommendations for improvements. We 
have certain standards and we are graded by those standards."
Stallings explains that the surveyor looks at some of the employees' 
records as well.
"They pull those, and we have to prove they are competent every 
year," Stallings said. "We have to show their education, that they 
were properly orientated to the hospital, that they are trained, how 
they were trained, where they went to school and that kind of thing. 
Everyone in this lab has either a two-year degree or a four-year 
degree. They also do what we call tracers."
Stallings said with tracers the surveyor pulls about eight charts 
from different dates from the past two years.
"This time she (the surveyor) pulled July 4, 2005, Christmas day and 
others," Stallings said. "The reason she pulled the charts from the 
holidays was because on those days you have less staff working and 
she wanted to make sure everything was still being done the way it 
was supposed to be done during those times."
Along with the employee records, quality control and charts, the 
surveyor checks the routine maintenance of the machines, such how 
they are cleaned.
"If you don't do what the manufacturer says to do as far as cleaning 
the instrument it cannot run like it is supposed to," Stallings said. 
"So they look at those records and the documentation of those 
records. It really is an intense survey."
The first day of the survey the surveyor does an exit interview with 
those in the lab and then the second day the surveyor shares the 
findings with the hospital administrator.
"At the end of the second day they give you a typed report that 
tells you what you did wrong or right and their recommendations," 
Stallings said. "That report is sent to the state health department. 
The state health department reviews everything we do, and if the 
reports are bad they could shut us down."
The reports weren't bad, however. The surveyors didn't find anything 
wrong. Stallings said the surveyor made one supplemental recommendation.
"It wasn't a deficiency," Stallings said. "It was a recommendation 
that we should do this and it has already been corrected. "Up until a 
few years ago you got a grade, you got a percentage. Now you either 
pass or you fail."
Stallings said if the Great River Medical Center lab had gotten a 
grade it would have been 99 percent.
"That is about as good as you can get," Stallings said. "I'm very 
pleased with it. I can't say enough about the staff and the job they 
do. You know that day in and day out everybody is doing a good job. 
They are doing the documentation, they are doing what they are 
supposed to. It shows how competent your staff is."
Stallings said the hospital has made 100 percent on a survey before 
and he can never remember being graded below a 92. He also said that 
just because the survey is over with, it does not mean the staff can 
relax.
"This is an on-going process," Stallings said. "You can't let things 
fall behind here. You have to do this every day."
 

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