JPS Achieves Stellar Results for 2021 CAP Survey of Laboratory

Accreditation survey highlights remarkable turnaround for JPS Lab team

Team Members in the Know

JPS Health Network’s Lab Administration team is celebrating the outstanding results achieved in its bi-annual inspection of on-site facilities for re-accreditation by the College of American Pathologists (CAP).

The 2021 CAP Survey of JPS Laboratory facilities found that out of over 3,000 standards reviewed, JPS met or exceeded all but four standards, and those were quickly corrected on site to the satisfaction of inspectors.

“Our Lab went through a near perfect CAP inspection, and I’ve never been a part of a CAP inspection this good in my life,” says Doug Chung, JPS Vice President for Clinical Ancillary Services. “So good that it required zero responses back to the College. It shows that despite COVID-19, we are still taking care of our patients in a high-quality manner on a daily basis.”

Dr. Janet Miles, Medical Director for the Laboratory, says this stellar result was a long time in the making. “It’s pretty remarkable, considering the journey this lab has taken on since 2015.”

Back in 2015, the CAP survey of JPS revealed a total of 138 deficiencies, which prompted another CAP inspection for the following year instead of the usual two years.

Those difficult survey results also sparked a long-term internal review of Lab’s processes, and a top-to-bottom re-evaluation of how JPS should go about meeting crucial standards.

The Lab’s leadership team developed a comprehensive quality management program over the past five years that has been fully adopted by staff.

“We basically took the engine out of our operation and put in a new one,” says Dr. Miles. “We gave our staff the tools they need to do the job well, from policies to processes, technology and systems. Now we have ways to track data and performance that allow us to serve patients better and more accurately.”

We basically took the engine out of our operation and put in a new one

This year’s results were a culmination of significant improvement seen in every survey since 2015, which was no simple task. JPS Lab Administration maintains a total of 21 checklists containing about 3,000 standards which must be maintained for accreditation purposes.

“This speaks to the hard working team in the Lab, and it speaks to the leadership of Doug Chung and Dr. Janet Miles,” says JPS CEO Robert Earley. “When you’ve had a tough survey and you’re able to pick yourself back up, that speaks an incredible amount about the folks working so hard down in Lab because they’ve taken it on the chin. To be so strong, and to get a CAP Survey like we have now, is just amazing.”

Dr. Miles says the dedication of everyone on the Lab team made all the difference. “To get to this point in five years has involved incredible teamwork on the part of our team. I could not be more proud of my team. Talk about North Texas heroes, I’ve got a bunch of them right here.”

The improvements in Lab Administration won’t stop there. The team is now on the cusp of implementing its highly touted new Beaker system, which should create more efficiency and improvements to the connectivity between Nursing and Lab, by integrating data better and more easily across the entire network. The Beaker system launch is planned for late fall.