SCOPE OF SERVICE
FOR DEPARTMENT OF PATHOLOGY
- 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.
- Scope of Services:
- 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.
- The Department of Pathology offers the following services:
- Clinical Pathology:
- Specimen Procurement (Phlebotomy, Specimen Processing, and
- Blood Bank and Transfusion Services.
- Chemistry (Clinical Chemistry and Special Chemistry).
- Hematology (includes Hematology, Coagulation, and Urinalysis).
- Microbiology (includes Bacteriology, Parasitology, and
- Anatomical Pathology:
- Histopathology (surgical and anatomical pathology processing and
- Cytopathology (gynecologic and nongynecologic services).
- Autopsy and Morgue Services.
- 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.
- 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.
- 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.
- 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
- 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
- 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).
- 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.
- Access to Care:
- 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.
- 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.
- 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.
- Complexity of Patient Care Needs:
- 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.
- 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.
- 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.
- Extent to Which Level of Care Meets Patient Needs: Patient needs are
assessed by the following means.
- 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.
- 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.
- 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
- 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.
- Appropriateness/Clinical Necessity/Timeliness of Support Services Provided
Directly by the Clinic/Service or Through Referral:
- 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
- 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.
- 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
- 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.
- Recognized Standards or Guidelines for Practice:
- 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.
- 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.
- 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.
- Methods Used to Access and Meet Patient Care Needs:
- 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.
- 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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