36C25819R0003-021.pdf

Phoenix VA Health Care System Phoenix, Arizona

Policy Memorandum No. 113-19 January 25, 2017

REFERENCE LABORATORY REVIEW MECHANISM

1. PURPOSE: To establish policy and procedures at the Phoenix VA Health Care System (PVAHCS) and its Community Based Outpatient Clinics (CBOCs) for utilization review of reference lab tests by a pathologist.

2. POLICY: All routine reference lab tests shall be reviewed by the Chief, Pathology and Laboratory Medicine Service (P&LMS), or designee, before sending out to appropriate reference laboratory. Emergency reference lab tests ordered during non administrative hours shall be expedited by the lead technologist/supervisor. The review is to accomplish the following objectives:

a. To ensure that prerequisite in-house testing is done.

b. To ensure the test is available within the scope of laboratory contracts .

c. To recommend substitution of an in-house test(s) which provide similar diagnostic information.

d. To recommend postponement of the test(s) until proper patient preparation is achieved to ensure validity of the result(s).

3. PROCEDURES:

a. Specimen Procurement and Distribution Section shall submit a list of reference lab tests to the Chief, P&LMS, or designee early each business day.

b. Chief, P&LMS or designee shall review the orders and the patient charts, communicate with ordering practitioners, and act within the scope of objectives cited above. Cancellation can only be made via agreement with the ordering practitioner and this shall be documented (notified, time, and technologist) in the comment section of VISTA.

c. The reference lab list is promptly returned to the Specimen Procurement and Distribution Section so that specimens will be processed and ready for pickup by 2:30 p.m. to 3:30 p.m.

d. Non-urgent orders received during weekends and holidays will be prepared for the next working day's review. Depending on the clinical situation, specimens may have to be collected on the day test(s) is ordered. Lead medical technologist/

Phoenix VA Health Care System Phoenix, Arizona

Policy Memorandum No. 113-19 January 25, 2017 supervisor may authorize STAT and As Soon As Possible (ASAP) orders during non-administrative hours.

e. Procurement and Distribution Section Supervisor reports a cost savings and volume to the Quality Assurance Coordinator (QA) monthly and a quarterly report consisting of utilization, turn-around-time and other issues in regard to our reference labs (documented in QA minutes).

f. Administrative Officer shall periodically review the status of reference lab funds to ensure availability. The Clinical Executive Board (CEB) annually approves the list of reference labs presented by the Chief, P&LMS.

4. RESPONSIBILITY: Chief, P&LMS is responsible for the implementation of this policy.

5. REFERENCES: None.

6. RESCISSION: Policy Memorandum No. 113-19 Reference Laboratory Review Mechanism dated September 10, 2013.

7. ATTACHMENTS: None.

8. FOLLOW-UP RESPONSIBILITY: Chief, P&LMS.

9. EXPIRATION DATE: January 2020 d&r/IJ~

RIMAANN 0. NELSON

Medical Center Director