质量和监管团队|概述
The Quality and Regulatory Team in the Department of Pathology at Boston Children’s Hospital is responsible for ensuring the department’s quality of service by aligning with the hospital’s plans and goals through participation in Quality Assessment and Performance Improvement activities. As well,the department assures compliance of processes by embedding regulatory standards into practice for continuous readiness of regulatory surveys and inspections.知名度和病理学人员的教育是团队的主要重点，其总体目标是提高患者安全性。
The Quality Triad works in conjunction with the Program for Patient Safety and Quality (PPSQ) to helpbuild a culture of safety and facilitate important work around outcome measures, process measures, and associated performance improvement initiatives. The department’s Quality Management Plan (QMP) is reported annually to hospital leadership forquality and safety activities that include Governance and Accountability, Event Review, Evidence-Based Review, Quality Improvement Initiatives and Normative Behavior.
TheQuality and Regulatory Teamconsists of the Director of Patient Safety & Quality, the Quality & Regulatory Manager, the Quality Improvement Consultant and the Pathology Laboratory Manager. Together they areresponsible for collecting, reporting, and analyzing quality data within the department in order to衡量绩效成果并开发用于绩效改进计划的工具。这些活动确保一致监视以提高患者护理质量并解决安全问题.
与病理相关的患者和安全事件通过医院的安全事件报告系统（SERS）进行了报告，并定期审查通过部门会议和论坛进行随访和讨论。For the most serious events, a structured Apparent Cause (ACA) or Root Cause Analysis (RCA) process is used to develop action items for preventing similar events in the laboratory, department and across the organization.
The Department of Pathology at Boston Children’s Hospital is licensed by the MassachusettsDepartment of Public Health (DPH), CLIA (Clinical Laboratory Improvement Amendments) certified by the Centers for Medicare and Medicaid Services (CMS), and accredited every 2 years by TheJoint Commission (TJC) through participation in a laboratory tracer survey.
The Joint Commission assesses and evaluates the laboratory’s compliance with selected standards and how the laboratory’s systems are prepared to provide care and services.为了确保遵守当地和联邦监管要求，质量和监管团队进行了持续的病理部门审计，以便provide an opportunity to review policies and procedures, and to identify areas of strength as well as opportunity for growth. Audits are conducted through tracer activities, similar to an actual Joint Commission survey, and include document and record review, as well as a safety and environment of care checklists.
The Regulatory Committee, which include members from each area of the Department of Pathology, support the Quality and Regulatory Team by meeting on a regular basis to help plan and guide regulatory and performance improvement activities. Members are responsible for communicating information to their respective co-workers. The Pathology Continuing Education Committee (PCEC) is responsible for developing, promoting and executing continuing education for laboratory staff as required to satisfy compliance of regulatory standards.
Please call the Department of Pathology at Boston Children’s Hospital for Quality and Regulatory questions or concerns at 617-355-7431.
Download the TJC Accreditation certificate
