Walter Reed Bethesda Lab Completes Successful Inspection

Story Number: NNS111210-09Release Date: 12/10/2011 6:55:00 PM
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By Bernard Little, Walter Reed National Military Medical Center Public Affairs

BETHESDA, Md. (NNS) -- The Pathology and Laboratory Department at Walter Reed National Medical Center (WRNMMC) completed a "highly successful" unannounced inspection by the College of American Pathologists (CAP), Nov. 29.

Navy Capt. David Larson, Department of Pathology director at WRNMMC, said CAP inspection of the labs occurs every two years with an unannounced inspection at any time 90 days before the anniversary date.

"The inspectors had high praise for the quality of work performed by the department," Larson said. "They did identify a few areas for improvement, but nothing that directly or significantly affected the laboratory's ability to provide quality patient results."

CAP serves more than 17,000 physician members and laboratory communities worldwide and is considered "the gold standard" in laboratory accreditation. It is composed of board-certified pathologists who inspect to assure for overall quality management, safety and operation of laboratories.

"It's a peer inspection group," said Larson. He said that inspections are based on rigorous standards and includes in-depth checklist requirements with board-certified pathologists inspecting labs other than their own but of similar size. "It's about improving the lab you're inspecting and your lab."

Larson said all labs have to be accredited by the Centers for Medicare and Medicaid Services (CMS), which has granted CAP authority to do laboratory inspection. The Joint Commission also recognizes CAP accreditation, which can be used to meet many state certification requirements.

Larson credits the 350-member staff of the pathology department with its successful inspection and meeting the missions of WRNMMC daily. He describes the department as very diverse, which includes anatomical pathology, clinical lab (including chemistry, hematology, microbiology), and blood services (including transfusion and the blood donor center).

"We're a complex organization designed to meet the needs of patients and staff," Larson said. The lab provides analytical services supporting health care providers in the diagnosis of disease, preventative health care, and pre- and post-deployment screenings, programs essential to care for all military and civilian beneficiaries.

Navy Capt. Larry R. Ciolorito, lab manager, said approximately 300,000 tests are done monthly in the lab at WRNMMC. He added about 2,000 phlebotomy cases are done daily.

Larson added that the lab has been out in front in integration. He said before Walter Reed Army Medical Center and National Naval Medical Center merged to form WRNMMC, there were some "natural alliances" between the centers' labs.

"Our residency programs for pathology had been an integrated since 1995," Larson said. In addition, he said there were already a lot of interactions between the staffs and consolidation of testing before the merger. "So we've known each other for a long period of time and integration was just a natural step for us."

He said the successful unannounced inspection in November was validation for the lab that integration is performed correctly and safely for patients and staff.

Larson said a conscious decision was made to move up the biannual CAP inspection from the summer of 2012 to this month in order "to make sure we hadn't missed something in bringing the two labs together and to avoid putting our patients and staff at risk."

Ciolorito said with the challenges and changes that have come with integration, which he described as an "enormous effort," it was courageous of Larson to request to move up the lab's inspection. Larson said the quality of the lab's leadership team and staff didn't give him pause in requesting to move up the inspection.

"This is a reflection of the entire laboratory team," Larson said of the recent successful inspection. "Even if a person's role was to take care of the specimen in front of him or her, that person was doing his or her part in integration and helping us maintain accreditation, because that's what we do - we take care of patients."

Larson said people may not understand all that goes on in the lab, but, "there's a whole lot of highly-technical, highly-professional, well-trained individuals ensuring the results that come out are quality results."

"It's impossible to have done what we have done, and are doing, without a truly joint and unified approach on the part of our staff," Ciolorito said.

"We have good people," Larson said. "They are hard working and professional."

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