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About the team

The Quality and Regulatory Team in the Department of Pathology at Boston Children’s Hospital is responsible for ensuring the department’s quality of service by aligning with the hospital’s plans and goals through participation in quality assessment and performance improvement activities. As well, the department assures compliance of processes by embedding regulatory standards into practice for continuous readiness of regulatory surveys and inspections. Informational awareness and education of Pathology staff is the main focus of the team with the overall goal of improving patient safety.

The Quality Triad works in conjunction with the Program for Patient Safety and Quality (PPSQ) to help build a culture of safety and facilitate important work around outcome measures, process measures, and associated performance improvement initiatives. The department’s Quality Management Plan (QMP) is reported annually to hospital leadership for quality and safety activities that include governance and accountability, event review, evidence-based review, quality improvement initiatives, and normative behavior.

The Quality and Regulatory Team consists of the Director of Patient Safety & Quality, the Quality & Regulatory Manager, the Quality Improvement Consultant, and the Pathology Laboratory Manager. Together they are responsible for collecting, reporting, and analyzing quality data within the department in order to measure performance outcomes and develop tools for performance improvement initiatives. These activities ensure consistent monitoring for improving patient quality of care and addressing safety concerns.

Pathology-related patient and safety events are reported through the hospital's Safety Event Reporting System (SERS) and reviewed regularly for follow-up and discussion through department meetings and forums. For the most serious events, a structured Apparent Cause (ACA) or Root Cause Analysis (RCA) process is used to develop action items for preventing similar events in the laboratory, department and across the organization.

The Department of Pathology at Boston Children’s Hospital is licensed by the Massachusetts Department of Public Health (DPH), CLIA (Clinical Laboratory Improvement Amendments); certified by the Centers for Medicare and Medicaid Services (CMS); and accredited every two years by The Joint Commission (TJC) through participation in a laboratory tracer survey.

The Joint Commission assesses and evaluates the laboratory’s compliance with selected standards and how the laboratory’s systems are prepared to provide care and services. To ensure compliance with local and federal regulatory requirements, the Quality and Regulatory Team conducts ongoing pathology department audits in order to provide an opportunity to review policies and procedures, and to identify areas of strength as well as opportunity for growth. Audits are conducted through tracer activities, similar to an actual Joint Commission survey, and include document and record review, as well as a safety and environment-of-care checklists.

The Regulatory Committee, which include members from each area of the Department of Pathology, support the Quality and Regulatory Team by meeting on a regular basis to help plan and guide regulatory and performance improvement activities. Members are responsible for communicating information to their respective co-workers. The Pathology Continuing Education Committee (PCEC) is responsible for developing, promoting, and executing continuing education for laboratory staff as required to satisfy compliance of regulatory standards.

Please call the Department of Pathology at Boston Children’s Hospital for Quality and Regulatory Team questions or concerns at 617-355-7431.

Download the TJC accreditation certificate

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Contact the Department of Pathology