Compliance

The PGL Program

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ACCREDITATION
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PGL's Laboratory is accredited by the College of American Pathologists (CAP) - view certificate


COMPLIANCE OFFICER
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Qualifications: B.S. in Medical Technology with certification by ASCP and current LA Medical License for Medical Technologist - Generalist; over 10 years of experience in a clinical lab setting Consults with clients to ensure compliance with regulatory agencies. Serves as a reference source for compliance issues for laboratories directed by PGL Pathologists. Supervises, monitors and reports on the PGL Quality Improvement Program


GOAL
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The goal of PGL's Quality Improvement (QI) Program is to provide excellent laboratory results, to constantly improve the performance and efficiency of the laboratory and to ensure optimal patient care.


DESIGN
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The QI Program is designed to follow the Joint Commission on Accreditation of Health Care Organizations' (JCAHO) 10 step process for monitoring the quality and appropriateness of patient care. The Compliance Committee (consisting of Pathologists, managers, and administration) directs the QI process. The activities that are integral to PGL's QI Program are:

- Cytologic and Histologic Correlation

- Intraoperative Consultations/Final Report Correlation

- Turn around time monitoring

- Consultation and Peer Review

- Peer education/self-assessment programs

- Quality review of the diagnostic report

Reviews for Surgical Pathology & Non-Gynecological Cytology Cases

- Prospective Case Review

- Previous specimens and patient history

- Cytologic and Histologic Correlation

- Intradepartmental consultations

- Extra-departmental consultations at the request of Pathologist

Retrospective Case Review

- All reports are reviewed daily

- Review of preliminary and final diagnoses in Intraoperative consultations

- Tissue Slide Review – random cases from various facilities and specimen types are pulled for Pathologist review. Cases are reviewed to ensure the accuracy of diagnosis in final reports.

- Autopsy review for correlation with medical findings

- Extra-departmental consultations at the request of patient and physician

- Turn around time of Intraoperative Consultations diagnosis

- Turn around time of surgical pathology reporting

- Turn around time of cytology reporting

- Turn around time of autopsy reports (preliminary and final)

- Cancer reporting checklist – the final reports of random malignant cases are scrutinized against the reporting requirements of the State Tumor Registry and American Joint Commission on Cancer for compliance with reporting requirements

 

The Laboratory Director of each facility or hospital designs QI activities to meet the specific needs of the partner facility.


COMPLIANCE CONTACT NUMBER
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225-706-4416