We are proud to share that the Department of Pathology and Laboratory Medicine at the University of Vermont Medical Center received re-accreditation from the College of American Pathologists (CAP). CAP accreditation is considered one of the best and most rigorous in laboratory medicine, and the staff in the laboratory at the UVM Medical Center works hard to reach the highest level of quality afforded in laboratory medicine.
Twelve inspectors from Children’s Hospital in Cincinnati, Ohio, spent two days performing the inspection, and in their summary, they offered many positive comments about our lab. These comments included:
- “Turnaround times on lab processing were very good.”
- “Staff in the Lab displayed great communication among their colleagues and excellent handoff communication practices.”
- “Exemplary proficiency testing in all divisions.”
Why are inspections necessary?
Seventy to eighty percent of all diagnoses and decisions in medicine rely on laboratory results. Knowing this, it is important that a lab provides timely and accurate results. From the time a clinical medical provider, such as a doctor or nurse practitioner, orders a test, many steps must occur quickly and properly to ensure the result is accurate. The lab is responsible for ensuring every step occurs properly and free from errors, beginning with ordering the test and ending when a result is reported.
How many patient samples does the lab at the UVM Medical Center process each year?
Approximately 2.7 million clinical laboratory tests are performed each year. Approximately 1 million specimen containers are processed for these 2.7 million tests. That includes 37,350 tissue samples, which require that 224,912 glass slides be prepared and reviewed by board-certified pathologists.
The Department of Pathology and Laboratory Medicine is a regional reference lab that receives specimens from many locations in northern New England. Though many of the specimens are from patients in Chittenden County, samples are collected throughout Vermont, northern New Hampshire, and northern New York. Our pathologists also receive requests to review tissue samples from all over the United States.
How does the laboratory at the UVM Medical Center prepare for inspections?
The standards the lab is expected to meet are outlined in a number of checklists. Each discipline in the lab for example hematopathology, chemistry, microbiology, cytology, surgical pathology, meets the standards outlined in these checklists. In total, the checklists cover approximately 2,300 items. Because these checklists are so lengthy, and given the inspections are unannounced, the lab remains inspection-ready at all times. In addition, the lab is expected to perform a complete self-inspection biennially . This self-inspection takes approximately one month to complete, and the Results of this self-inspection are reviewed when the CAP inspection team arrives to perform the official inspection.
The Department of Pathology and Laboratory Medicine understands how valuable the inspection process is for maintaining optimal patient care. Everything we do is in service to the patient.
The laboratory uses the self-inspection process to engage and educate the pathology resident physicians by having them perform the self-inspections under the guidance and close supervision of the managers, supervisors, and pathologists in the lab. By including our pathology residents in the inspection process, they become aware of the critical steps in laboratory medicine and take this knowledge with them when they graduate our program.
Is the lab at the UVM Medical Center only inspected by CAP?
The Department of Pathology and Laboratory Medicine at the University of Vermont Medical Center and the University of Vermont is inspected by many regulatory and accreditation agencies.
These agencies include:
- American Association of Blood Banking
- American Society for Histocompatibility and Immunogenetics
- Food and Drug Administration
- Foundation for Accreditation of Cellular Therapy
- New York State Department of Health
- The Joint Commission
- Center for Medicare & Medicaid Services
- American College of Surgeons
- National Radiation Council
- Cytotechnology Programs Review Committee
Labs reviewed during the inspection include:
- The core lab in the ACC building
- The autopsy suite
- Electron microscopy at the Health Science Research Facility
- The molecular lab at the Colchester Research Facility
- Fanny Allen clinical lab
- Point of care testing sites throughout the facility
The Department of Pathology and Laboratory Medicine exceeds the standards set by numerous accrediting agencies. Our450 staff members are dedicated to providing accurate and timely results that contribute to the health and well being of all the patients our laboratory serves.
For more information about this lab or laboratory medicine in general, please contact Andrew Goodwin, MD, by calling 802-847-5121. You may also arrange for a tour of the lab by calling Colleen Williams at 802-847-9473. Learn more about Laboratory Services at the UVM Medical Center.
Andrew Goodwin, MD, is Medical Director of the Coagulation Laboratory in Pathology & Laboratory Medicine at the University of Vermont Medical Center.