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SCOPE OF SERVICE

FOR DEPARTMENT OF PATHOLOGY

  1. The Department of Pathology is a modern, fully accredited facility offering a full range of clinical laboratory and anatomical pathology services. The Chief, Pathology serves as the Medical Director; and as overall head of department is responsible to the DCCS.
  2. Scope of Services:
    1. The primary mission of Department of Pathology is to provide timely, accurate and appropriate pathology services in support of patient care and military readiness. Pathology also supports initial and sustainment laboratory training for active and reserve military personnel as part of the readiness mission.
    2. The Department of Pathology offers the following services:
    1. Clinical Pathology:
    1. Specimen Procurement (Phlebotomy, Specimen Processing, and Shipping).
    2. Blood Bank and Transfusion Services.
    3. Chemistry (Clinical Chemistry and Special Chemistry).
    4. Hematology (includes Hematology, Coagulation, and Urinalysis).
    5. Microbiology (includes Bacteriology, Parasitology, and Serology).
    1. Anatomical Pathology:
    1. Histopathology (surgical and anatomical pathology processing and reporting).
    2. Cytopathology (gynecologic and nongynecologic services).
    3. Autopsy and Morgue Services.
    1. Off-Site Laboratory Testing: Waived and moderately complex clinical laboratory procedures are utilized at Troop Medical Clinics on Fort Carson and Pinon Canyon Maneuver Area. Each site has a DOD Clinical Laboratory Improvement Program (CLIP) certificate as required by law.
    2. Point of Care Testing (POCT) is available at numerous wards, clinics, and services. POCT includes waived (minimally complex), moderate complexity, and Provider Performed Microscopy (PPM). Each site has a DOD CLIP certificate as required by law.
    3. Consultative Services: The Department of Pathology serves as the Pathology Consultant for Dugway Army Health Clinic Laboratory. Dugway AHC has its own College of American Pathologists (CAP) accreditation and CLIP Certificate.
    4. A Laboratory Services and Specimen Collection Manual is reviewed yearly, and updated and published as required. This document is provided to each healthcare provider, ward, clinic, or service. Laboratory test information, such as reference ranges and specimen requirements, is available through the hospital information system CHCS.
    1. Administrative support for the Department is provided by the Laboratory Manager, Non-Commissioned Officer in Charge (NCOIC), Quality Improvement Coordinator, Secretary, Case Coordinator/Transcriptionist, and a Supply Technician.
    2. The Department is a Phase II training site for the US Army Medical Laboratory Technician Course. The course is administered by the US Army Medical Department Center and School in conjunction with George Washington University. The course is accredited by the National Accrediting Agency for Clinical Laboratory Sciences (NAACLS).
  1. Types and Ages of Patients Served: Pathology provides specimen collection and testing procedures for all active duty military, eligible reservists, military retirees, family members of active and retired military, and other eligible beneficiaries. Patient age ranges from newborn to elderly.
  2. Access to Care:
    1. Location: Pathology is located on the first floor of building 7500 in the southeast corner. The Morgue and Autopsy Suite are located on the Service level in rooms 0711 and 0714, respectively.
    2. Hours of Operation: The Clinical Pathology sections of Pathology operate 24 hours a day. The Specimen Procurement section operates from 0700 to 1700 Monday through Friday (excluding holidays). Ward rounds are performed Monday through Friday (excluding holidays) at 0500. Anatomic Pathology is operated from 0730 to 1630 Monday through Friday (excluding holidays), with an on-call tech available. A pathologist is always available on-call.
    3. Patients access direct care by presenting to the Specimen Procurement section for outpatient services, by admission as an inpatient, or having a clinical specimen collected by a healthcare provider during a patient appointment. Healthcare providers are responsible for entering electronic orders into the hospital information system or providing the patient with a handwritten order. Outpatients presenting for care must provide proper identification and valid electronic or handwritten orders must be available. Patients without orders are referred back to their healthcare provider after the laboratory has made an effort to obtain orders from the provider. Inpatients are identified by identification bracelets and asking the patient their name before blood specimens are collected.
  1. Complexity of Patient Care Needs:
    1. Pathology provides primary patient care to inpatients and outpatients through specimen collection services. Phlebotomists collect blood samples from outpatients visiting the Specimen Procurement section and from inpatients during ward rounds. Specimen Procurement personnel instruct patients in proper collection of urine and stool samples, as well as administering glucose tolerance testing.
    2. Clinical Pathology performs minimally, moderately, and high complexity testing for body fluid and other specimens. Testing is available on a routine, ASAP, and STAT basis. The Laboratory Services and Specimen Collection Manual provides a list of which tests are available on a STAT or ASAP basis.
    3. Anatomic Pathology provides high complexity surgical pathology, cytology, and histology services. Fine-needle aspirate (FNA) services are available for patients. Pathologists are available to perform intraoperative frozen section surgical pathology services. Medical autopsy services are available at this facility; however, any forensic autopsies are referred to civilian or higher level military authority.
  1. Extent to Which Level of Care Meets Patient Needs: Patient needs are assessed by the following means.
    1. Quality Assurance Incident Reports, formal and informal patient or provider complaints, DOD/Tricare satisfaction surveys, local satisfaction/comment cards, and utilization review are some of the methods utilized to assess the level of care.
    2. Pathology monitors its test menu to determine if the appropriate testing services are available though utilization review and field comparisons. Additional information is provided by professional conferences and publications, medical and nursing staff satisfaction surveys.
    3. Pathology evaluates its normal and critical values for clinical efficacy in critical patient care situations through consultation with the medical staff, professional literature and consultation with external laboratory agencies
    4. Private and TriCare network healthcare providers are allowed to order laboratory tests for patients eligible for care in the Military Healthcare System. Providers express their level of satisfaction either by contacting the laboratory directly or through TriCare administration.
  1. Appropriateness/Clinical Necessity/Timeliness of Support Services Provided Directly by the Clinic/Service or Through Referral:
    1. Support Provided: Clinical Pathology performs approximately 320,000 patient reportable tests each year. Approximately 50,000 outpatient and 2,600 inpatient phlebotomies are performed annually. Anatomic Pathology processes and reports approximately 6000 surgical cases, over 9500 gynecologic cytology specimens, and approximately 500 non-gynecological cytology specimens every year. Approximately ten autopsies are performed each year.
    2. Support Services Sources: To ensure appropriate and timely pathology support numerous military and civilian resources are utilized. Military laboratories are the primary source of reference laboratory services, with additional support obtained from civilian reference laboratories. The College of American Pathologists or an equivalent agency accredits all laboratories utilized. Blood products are obtained either from military sources or Belle Bonfils Memorial Blood Center. Most equipment is leased from the manufacturer on cost-per-test basis, with repair and maintenance provided by the vendor. Purchased equipment is either maintained directly by the Biomedical Maintenance Branch or by a contractor.
    3. Appropriateness, Clinical Necessity and Timeliness: To ensure providers order tests appropriately each section monitors test usage through workload reports and supervisory review of laboratory test results. Clinical necessity is monitored by the same means, as well as Pathology providing provider profiles on laboratory use to Clinical Support Division upon request. Pathology continually evaluates its services through quality assurance indicators, several of which monitor turn-around or reporting times.
  1. Availability of Necessary Staff: Personnel are assigned to the Department based on the Table of Distribution and Allowances (TDA). Staffing for this TDA is based on historical workload entered into staffing models devised by Resource Management. Many of the staff are specialized, whereas others are cross-trained to provide the depth necessary to provide around the clock services. Services are provided by two military Pathologists, one Laboratory Officer (Medical Technologist), one Non-Commissioned Officer in Charge (NCOIC) (Medical Laboratory Technician), one QI Coordinator (Medical Technologist), four Supervisory Medical Technologists, thirteen Medical Technologists, ten Medical Laboratory Technicians, six Medical Technicians, one Supervisory Pathology Technician, two Cytotechnologists, and two Histotechnicians.
  2. Recognized Standards or Guidelines for Practice:
    1. Primary practice guidelines and standards for Pathology come from professional organizations such as College of American Pathologists (CAP), American Society for Clinical Pathology (ASCP), American Association of Blood Banks (AABB), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Food and Drug Administration (FDA). CAP and the AABB accredit the department. The Blood Bank is a licensed site with the (FDA). POCT is accredited under the JCAHO. Other professional organizations such as American Society of Microbiology (ASM), American Association of Clinical Chemistry (AACC), American Society for Clinical Laboratory Science (ASCLS) provide additional professional guidance. Numerous Federal laws, Department of Defense and Army Regulations, as well as other standards of practice apply to the department.
    2. Numerous employees have voluntarily achieved national registry and certification with organizations such as the American Society for Clinical Pathology (ASCP), National Certification Agency (NCA) and the American Society for Medical Technology (ASMT) as Medical Technologists, Clinical Laboratory Scientists, Medical Laboratory Technicians, Histotechnicians, Cytotechnologists, and Phlebotomists. While this achievement is not required for federal employment, completion of this difficult examination demonstrates a level of professionalism and competency among personnel.
    3. Personnel competency, orientation, and continuing education, as well as instrument and system reliability are maintained by in-depth competency-based orientation and training. This is accompanied by and followed-up with participation in interlaboratory comparisons and proficiency surveys provided by the College of American Pathologists (CAP) and other sources. Pathology actively participates in teleconferences, inservices, and off-site training offered by professional organizations.
  1. Methods Used to Access and Meet Patient Care Needs:
    1. Pathology monitors appropriateness of care, timeliness, and customer satisfaction through various Quality Improvement Indicators. Each month the Pathology Quality Improvement Committee meets to review these indicators, analyze trends, and address incident reports and customer service issues. This data is evaluated and incorporated into the hospital Quality Improvement Program to ensure patient care needs are met.
    2. Pathology has a documented Quality Assurance and Performance Improvement Plan that is reviewed and updated annually. It is a continuous, integrated, and comprehensive program that uses clinical indicators and thresholds for systematic evaluation and improvement.

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