Chapter 1: General Concepts and Administrative Issues
Strategic Planning
1. Deciding on the objective of the organization and the need to modify existing objectives 2. Allocating Resources to attain these objectives 3. Establishing policies that governs the acquisition, use, and disposition of these resources
Maintenance log
2 years
accession log
2 years Retention
Reacquisition
2 years retention
muscoskeletal disorders (MSDs)
Affects the muscles, nerves, blood vessels, ligaments and tendons
10 years
Blood Bank Donor/Reciept Records
10 years
Blood Bank Patient Records
5 years
Blood Bank QC records
indefinitely
Blood bank deferred donor records
10 years
Blood bank employee signature/initials
7 days
Blood/Fluid Smears
Top Manager
CEO
Top manager
CFO
Top Manager
CIO
Corrosive
Chemical which corrode substance while in contact
Rop Manager
Chief Executive
First Line
Chief Technologist
2 years
Clinical Pathology test results
CQI
Compares traditional thinking vesus TQM
Top Managers
Concentrates on Strategizing and planning for the next 1 to 5 years
tactical planning
Consits of the detailed, day to day operations needed to meet the immediate need of the laboratory
2009 HITECH Act
Contains incentives vrelated to adoption of health care information technology and the electronic health record set goal of "meaningful use"
20 years
Cytogenetic reports/images
3 years
Cytogenic slides
5 years
Cytology slides
2003 Hazardous Material Regulations
Deals with shipments of blood and other potentially biohazardous products
Six Sigma Steps
Define, Measure, Analyze, Improve, Control
30 inches
Desk Height
3 square feet
Desk Space
Nuclear Regulatory Commission (NRC)
Develops and enforce federal guidelines that ensure the proper use and operation of non military nuclear facilities
1996 Health Insurance Portability and Accountability Act (HIPAA)
Direct how health care information is manage. This law protects patents from inappropriate dispersion of personal information.
Waste Management
Disposal or recycling and monitoring of waste
Middle Manager
Divisions Head
CQI
Element of TQM that strives to continually improve pratices and not just keet established quality standards
1989 Ergonomic Safety and Health Program Management Guidelines
Established OSHA Guidelines for employee safety
1984 Deficit Reduction Act
Established outpatient laboratory fee schedule to control cost
Clincal Laboratory Improvement Act of 1988
Established that all laboratory must be certified by the federal government with mandated quality assurance, .....
10 years
FNA slides
10 years
Flow Cytometry plots/Histograms
Center for Medicare and Medicaid Services (CMS)
Formerly known as the health care financing administration (HCFA)
Planning and Propmt decision Making Leading Organizing Controling
Four Primary Management Functions
human, financial, physical, informational resources
Good Management uses
1997 OIG Compliance Guidelines
Help laboratories develop programs that promote high ethical and lawful conduct
6square feet
Human Body Sitting
4 square feet
Human Body standing
Department of Homeland and security (DHS)
Identifies and Regulates and may inspect high risk chemical facilities and radiation sources
Supporting Delegating Directing Coaching
Key Leadership styles
25 to 27 inches
Keyboard drawer height
7 feet
Laboratory Counter to Counter Clearance
Top Manager
Laboratory Director
4 feet
Laboratory counter to wall clearance
2 feet 6 inches
Laboratory counter width
5s PDCA
Lean Utilizes varities of technique including
Viruses
Living virus needs host
First line manager Middle manager top manager
Manager can be stratofied as:
Oxidizing
Materials that spontaneously evolve oxgen that promote combustion
7 days
Microbiology Stained Slides
Parasite
Multi-celled organism
1992 Occupational Exposure to Blood-Borne Pathogens
OSHA Guidelines to limit exposure to biological hazards
1990 Occupational Exposure to Hazardous Chemicals in Laboratory
OSHA Guidelines to limit unnessary exposure to hazardous chemicals
Middle Manager
Opertions manager
Fungi
Organism that produces toxins
US Department of Health and Human Services
Oversee CMS, OIG and FDA
Equal Employment Opportunity Commission (EEOC)
Oversee and enforces title VII dealing with fair employment practices
Center for Medicare and Medicaid Services (CMS)
Oversees the largest health care program in US
10years
Paraffin Blocks/slides
1990 Three-Day Rule
Payment of any laboratory testing done 3 calendar days before admission
1989 Physician Self-Referal Ban
Prevent physicians from reffering medicare patient to self owned laboratories
Strategic Planning
Process by which high-level decisions are made
Management
Provides the "road" to get there
2 years
Quality Control records
2001 CMS National Coverage Determination
Replaced most local medical review policies used to determine whether certain laboratory tests are medically necessary and therefore reimbursable
10 years
Reports
Office of the Inspector General (OIG)
Responsible for audits, investigations, inspections, and identifying fraud and abuse in CMS
2 years
Retired Laboratory Procedures
Social Technologic Economic Environmental Political
STEEP
48 hours
Serum/CSF/Body Fluids
Bateria
Single Celled living organism
TQM thniking
Stives to contually look for waysto reduce errors
Middle Manager
Stradle both areas to some degree
Flammable
Substance which may be ignited by source of ignition
Explosive
Substances may explode due to a source of ignition
Radioactive
Substances that generate radiation
Biological Hazards
Substances that pose a threat to The health of the living organisms primary that of humans.
Appropriate data collection Observing Current Projected conditions
Successful Strategic Planning requires
First line
Supervisors
10 years
Surgical Pathology slides
First Line
Team Leaders
LEAN Six Sigma
Two other tools often used to improve quality throuhout the health care industry
Physical Chemical Biological Ergonomic Psychological
Types of Hazards
24 Hours
Urine
Strategic planning
Usually based on long term projections and a global view
2 weeks
Wet tissue
Plan Do Check Act
What does PDCA stand for?
National Institute of Standards and Technology (NIST)
a branch of the Commerce Department and has contributed to the development of many health care products.
Leadership
a pattern of behavior used to engage others to complete task in a timely manner
Six Sigma
a structured process based upon statistics and quantitative measurement which process defects or error are analyzed
labor
accounts for 50 to 70 percent of laboratory's cost
National Institute of Health (NIH)
agency of HHS and is a world leader in medical research
Chemical hazards
any
Defect
anything that does not meet customer requirement
Regionalization
consolidation process on a grand scale
Lean
developed from the priciples used by the Toyota Corporation
Occupational Safety and Health Administration (OSHA)
enforces workplace standards to protect employee s' safety and health
Biological Hazard
exposure to bacteria, viruses, parasites or other biological entities.
1983 Prospective Payment System
for Medicare established payment based on diagnosis related groups
Clinical and Laboratory Standards Institute (CLSI)
formely NCCLS develops standardized criteria regarding laboratory practices
U.S. Department of Transportation
has the responsibility of regulating biohazardous materials that includes blood ajd other human products
U.S. Food and Drug Administration (FDA)
is a part of HHS and regulates the manufacture of biologics and medical devices and test kits
The Joint Commision (TJC)
is an independent not for profit entity that accredits nearly 17000 health care oraganizations and programs in US
American Society for Clinical Pathogens (ASCP)
largest organization for laboratory proffesionals amd offers certifications for various Specialties
Wrong Decisions
may burden a laboratory with unnessary cost.
First Line
more concentrated on completion of day's work
Commission on Office Laboratory Accreditation (COLA)
organize to provide assistance to physicians
National Institute of Occupational Safety and Health (NIOSH)
part of HHS and provides research, information, education and training in the field of Occupational safety and health
American Association of Blood Banks (AABB)
peer of professional group that offers blood bank accreditation program.
Six Sigma
performance improvement program, the goal of which is to improve by eliminating process variation
Directing leader
presents rules, orders or other defined instructionsto that individual
National Archives and Records Administration (NARA)
provides a number of database, including access to federal register
Leadership
provides direction to where one is going
Coaching Leader
provides high support and direction
Delegating Leader
provides low suppprt and direction
Center for Disease Control and Prevention (CDC)
provides oversight of public health and safety, including laboratory
National Institute on Drug Abuse (NIDA)
regulates standards fro performing and maintaining appropriate quality control for drugs of abuse testing
Ergonomic Hazards
science of fitting the job to the workers
Environmental Protection Agency (EPA)
sets and enfores standards for disposal of hazardous laboratory materials
Total Quality Management (TQM) and Continuous Quality Improvement (CQI)
standard approches to quality leadership and management for over 30 years
TQM
system approach that focuses on teams, processes, statistics and delivery of sevices and etc. that meet or exceed customer expectations
Lean
system for reducing waste in production or manufacturing processes.
Safety
the condition of being protected from or unlikely to cause danger, risk, or injury.
Good Management
useds the most efficient and effective manner, the human financial physical and information resources available to an organization
State Department of Health
vary in extent to which they regulates laboratories. Oversee mandatory proficiency testing and laboratory inspection program
Sort Set in order Shine Standardize Sustain
what does 5s stand for?