Procedures stored electronically

[amym1586]

My pathologist came to ask me if we are handling this correctly.

He has to sign off on the tissue procedures and they keep all of their procedures stored electronically.

So every year they just change the date in the computer and have it electronically signed.

 

Is that cool with CAP and AABB ?

[Cliff]

What does your document management SOP say?

Is there a way to prove it was him?  How do you save the date / reviewer over the years?

[amym1586]

I have no idea. 

It's one of those they stick us with even though we have nothing to do with tissues.  

They are writing all their own procedures in surgery.   I guess I'll have to see if they have some documentation on the SOPs

[AMcCord]

We are using Media Lab and the rest of the hospital is using Policy Medical for all procedures. These document control systems have a password protected log in, they have permissions specific to the user log in (in other words, there are read only permissions, add and edit permissions, manager permissions, etc.), all new records are signed off by everyone within the system including supervisory approvals and employee sign off,  they remind us when a review is due and we review/document the review within the system.

Our supervisory lab signature is one that we wrote on paper and which was scanned into the Media Lab system. When we approve a laboratory procedure (we are logged into the system with our password), Media Lab asks for a pin # and it then attaches our 'signature' to the document. When you print an approved copy of the document out there are a couple of pages that show these 'signatures' for the supervisor, lab director and medical director, with date/time of the 'signature'. Our recent CAP inspectors loved it - everything is right there on a computer screen for them. (And when we get everything into Inspection Proof, all of us AND the CAP inspectors are going to love the simplification to inspection day.)

The Policy Medical system system has a history record that documents who reviewed the record based on the password protected log in to it, so it's 'signature' is electronic also, but without the handwritten one Media Lab adds. TJC wants everything in one place with document controls in place. They were quite happy with this system on our last inspection, which was in 2015.

Either way, there should be a policy that describes how documents are stored, reviewed and signed off.

As for the tissue policies, who is the one person with overall responsibility for them? If it's your medical director, you should be involved in the development of the policies and procedures. Not saying that's going to be easy. I agitated for years that lab needed to be involved and it wasn't until we got our new medical director and the right manager for surgical services that this happened. The surgical services manager appointed one of her nurses (who is terrific) to work with me to develop policies where lab and surgery overlap. For those overlap areas we use one policy for both lab and surgery. The primary is in Policy Medical and a copy of that policy is in the blood bank manual. All tissues are documented/controlled as if they were blood products. She and I 'own' the policies. The lab medical director is the overall responsible party for the tissues, with the next tier of control being the directors of lab and surgical services, followed by myself and my nurse partner, meeting TJC requirements very nicely. When TJC inspected us last, they complemented us on the quality of our tissue protocols. It was a bit of work to get set up, but worth it.

 

[tbostock]

Sadly yes, we are involved in tissues as our Medical Director is responsible for it.  I am now the Tissue Compliance Officer for our hospital after we were cited by TJC and NYS Dept of Health.  We now even have possession of all the tissues in the Blood Bank; we track it and issue it just like blood products.  It just about tripled our workload.

[MAGNUM]

We use compliance 360 for our procedures, and in order to sign off on a procedure you must have access to the procedure and then once myself then the pathologist clicks ok then his electronic as well as my electronic signatures are affixed.

[David Saikin]

Terri - my condolences on tissues

We use MediaLab for our policies/procedures.  sometimes it can be a bit obtuse but it maintains all the documentation needed for regulatory compliance.  We can manually attempt to write our name (which produces some really interesting results) or we can associate our name with a pin#.