Pathology Associates Of Lexington, P.A.

Rules and Regulations 1988

Rules/Regulations of the Pathology Division Of The Medical Staff

PHILOSOPHY:

It is the intent of the Pathology Department to bring its cumulative expertise together for the overall benefit of large numbers of patients and medical staff by performing examinations/tests expeditiously and with desired accuracy and quality commensurate with the total resources available. Under the direction of pathologists, the department represents, broadly, a specialty practice of medicine in which the individual patient/case, under unusual circumstances, assumes top priority over general laboratory operations. Within this setting, the department will be managed with a view toward progressive professional quality, a desire to benefit the hospital corporate entity, and a willingness to foster and promote harmonious inter-departmental relations: all with an underlying view toward the enhancement of the quality of medical practice in Lexington County. The Joint Commission on Accreditation of Hospitals' guidelines for standards will serve as quality guideposts while other standards and accreditation will be sought from time to time.

ORGANIZATION AND STAFFING:

The department shall be directed professionally by a pathologist certified by the American Board of Pathology. The Chief Pathologist and his associates in pathology will be members of the medical staff and will provide the professional expertise (at the medical doctor level) and direction for the pathology laboratories taking into consideration input from the medical staff, administrative, and other elements of the hospital organization and medical community. Locum tenens coverage will be under the pathologists' discretion.
Laboratory and pathology procedures and tasks will be delegated to suitable employees. In conjunction with the personnel department and considering widely accepted evidences of qualification, the Chief of Pathology and Chief Technologists will interview and review the records of and finally determine that a prospective employee is suited for a given employment opening. Termination of employment will follow general personnel guidelines and is likely to occur when an employee's actions or inactions are detrimental to the laboratory operations. The final decision for termination will be made by the Chief of Pathology and the Chief Technologist.

FACILITIES AND OPERATIONS:

Determination to increase or decrease the scope of operations within the hospital or by referral will rest with the pathologists (taking into consideration the objectives of the pathology group, the medical staff, and the hospital Board of Trustees). Equipment purchase and new space decisions will be negotiated with Administration. Specimens or case material will be referred for testing/consultation to laboratories/professional experts as determined qualified by the pathologists unless otherwise requested by the medical staff.
Final test results will be issued in writing to the place of request origin. STAT results and certain other special cases will be verbally reported preferably to the patient's physician but acceptably to hospital nurses or physicians' office employees with the request that they promptly bring the information to the physician's attention. Since lab workers cannot determine the urgency with which results are needed, their relative importance in a case, changes in location of a patient and his records; it must remain the responsibility of the physician ordering a given test to seek the result if it has not come to his attention after a period he deems timely.
The department will maintain and retain accession logs and/or work logs along with duplicate report files to back up 3(B), as a data source for medical audits and studies by such as tissue committees, transfusions committees, accrediting agencies, etc. Certain specimens or samples will be retained for lengths of time for retrospective test ordering or diagnostic use or for the purpose of forwarding, on behalf of a patient and his physician, to another institution for definitive treatment or consultation.
Continuing education will directly and indirectly be provided for employees/professional staff of the lab and its personnel, and resources made available to other areas of the hospital and to the medical staff.

RULES:

Tests/examinations generally will be performed according to procedures listed in the laboratory procedure manuals or references thereof. Exceptions may occur in consideration of unusual circumstances and with proper authorization and/or prior consultation.
To process a large work load, numerous rules exist in and emanate from the lab which have direct or indirect effects on patients, doctors, and hospital employees. These rules are constantly changing and are of large numbers. They exist in lab memoranda and procedure manuals available in the lab. Most can be explained by the technologists, and any exceptions should be through the pathologist on call.

COMPLAINTS ABOUT THE LAB:

The laboratory, in processing high volumes of requests, is bound to stimulate complaints. It is recognized that some have solutions, some do not, but all need to be brought to the attention of the proper persons. Many complaints revolve around rules and regulations under which laboratory personnel are required to work, e.g., how fast blood can be crossmatched. Constructive criticism/complaints should be directed to the Chief Technologist or pathologists as soon as possible. This can be done formally through incident reports or by other informal means. Constructive criticism is vital to the overall effectiveness of the laboratory operations and is solicited.