I recently took over as the blood bank supervisor, and I'm trying to consolidate some of our procedures. We currently have two procedures for emergency releasing blood, one for inpatients and one for the outpatient surgery center. I told my pathologist that I'd like to retire the outpatient surgery procedure, as it is still the same process and doesn't provide any additional information, but he thinks we might need it because the outpatient surgery center has a different CLIA number. I've never heard of this, do y'all have any idea what he could be referring to?

That doesn't make any sense to me but I've been out of the loop for awhile.  Is the outpatient surgery center a "stand alone" facility separate from the hospital or is it incorporated into the hospital?  I'm not sure if that would make a difference, just a thought. It still would not make sense to me to have two separate but identical procedures on file.

Do you have a good enough working relationship with your pathologist that you could ask him to explain his thinking to you?  I've had at least one medical director that I would not even consider questioning but on the flip side, I've had a couple that I had no qualms about asking for an explanation and one I didn't even have to be careful about how I phrased it!  A close working relationship with your medical director is the best thing you can cultivate.  

Good Luck                          

Once upon a time, our facility served 2 different CLIA numbers (clinic vs hospital, it was weird and complicated).  To satisfy "the rules" any policies or testing procedures that applied to both CLIA numbers had 2 different review/approval cover sheets; one for the hospital pathologist to sign off, one for the clinic medical director to sign off.

Hi John, it's a stand alone surgery center. Unfortunately, our pathologist isn't sure why we have two procedures, the separate CLIA numbers were his best guess. After speaking with a couple of other long time employees, I think it had to do with that surgery center not originally being owned by the hospital. I'm thinking that I'll just add a line about servicing outpatient facilities into the original emergency release procedure and retire the other one.

Kelly, thanks for your response! That makes some sense, I haven't run into a situation like that before.

If you provide blood for the outpatient surgery center it makes no sense to have two separate procedures for emergency releasing blood otherwise you would need two procedures for EVERY process that you do at both sites, and that would really suck