The results of the recent readership survey are in and we appreciate your input. More than 86 percent of you said you’d like to see more information about how to comply with specific standards, so we’re going to incorporate more standards related topics into the newsletter. In this issue, we added an Accreditation Workshop which features some of the questions asked of the lab experts in our Standards Interpretation Group. If you have a question you’d like to see answered in this feature, forward it to Pamela Schumacher, Lab Focus Editor, at pschumacher@jointcommission.org.
Another excellent suggestion was to provide more news from the field, so we included an article explaining the federal sanctions that can result if your organization refers proficiency testing samples to another lab for analysis. See the details.
Overall, the survey results showed that our readers appreciate the newsletter and the information we provide. We will continue to modify the content to more closely meet your needs in the coming issues. Read the complete story about the survey later in this issue. Meanwhile, if you have other suggestions for improving the content of Lab Focus, please send them to me at mpeck@jointcommission.org. I look forward to hearing from you.
Margaret Peck
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In this issue, Cherie Ulaskas, MT (ASCP), MA, associate director, Standards Interpretation Group, answers questions that she recently fielded from accredited laboratories.
Q: Do physicians need to demonstrate competency to do fern testing?
A: Yes. Fern testing is classified as a Provider-Performed Microscopy Procedure test. PPMP testing is not a waived test and therefore the waived testing standards do not apply.
As of January 1, 2007, all staff (including physicians) must demonstrate competencies for PPMP testing. This requirement changed for 2007 and is addressed in the Joint Commission Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing, chapter HR.3.10, EP #14, which states:
Staff members are evaluated for competence in performing required laboratory tasks as applicable, as well as for all other parameters defined in their job descriptions.
Note: All staff who perform PPMP testing, including all physicians, dentists, and midlevel practitioners as defined in CLIA 493.2, must participate in competency demonstrations.
Q: Are meter-to-meter correlations required on glucose meters?
A: It depends on the complexity of the meter. Correlations are not required on waived glucose meters. The standards do not require comparison or correlation studies of waived testing instruments, unless specifically required by the manufacturer.
If a glucose meter, or other instrument is of moderate complexity or higher, standard QC.1.80 requires that:
The laboratory uses a system to correlate and evaluate the relationship between the results for the same test performed with different methodologies or instruments at different sites.
If you have a question you’d like to see answered in the Accreditation Workshop, e-mail it to Pamela Schumacher, editor, pschumacher@jointcommission.org.
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The Clinical Laboratory Improvement Amendments prohibit labs from sending proficiency test samples to another laboratory for testing. There are no exceptions to this prohibition.
Consequences
CLIA’s regulatory enforcement policies will be implemented for any laboratory that refers any proficiency testing samples to another laboratory for analysis. The motive for the referral is irrelevant. Regulations stipulate that the referring lab be cited for “immediate jeopardy” to patient health and safety. The lab will have its CLIA certification revoked for at least one year. In addition, the owner(s) and operator (including the medical director) of the laboratory will be prohibited from owning, operating, or directing any laboratory for at least two years from the date of revocation, whether they knew of the referral or not.
If your lab is sent another lab’s PT samples
Any laboratory that receives proficiency testing samples from another laboratory for testing is obliged to notify CMS of the receipt of those samples.
For more information, see the CLIA website, www.cms.hhs.gov/clia.
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Expect to see changes in Lab Focus that will increase the value of the newsletter as a result of the recently completed readership survey, says Margaret Peck, executive director, Laboratory Accreditation Program.
Of the 601 respondents to the recent readership survey, 74 percent were from Joint Commission accredited labs. Eighty-one percent always or sometimes read each issue. The standards Q&A columns are generally the most well-read at 64 percent, followed by feature articles at 52 percent and the Newsline column with 38 percent of respondents reading them frequently.
Article length was spot on with 94 percent of respondents saying that feature articles were about right, 84 of respondents liking the length of Q&A articles, and 92 percent positive about the length of Newsline.
In the open ended section, respondents said they would like to see more examples of how to meet the standards in innovative ways; strategies for meeting the NPSGs; and would like the newsletter to be more proactive about new issues in health care.
“We’re pleased that Lab Focus is well regarded by its readers. We’ve already implemented some of the suggestions in this issue. The new Accreditation Workshop feature is a direct response to feedback from the survey,” says Peck. “We will continue to plan further improvements for upcoming issues.”
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The Joint Commission Perspectivesâ provides accredited laboratories with a monthly update about revisions to the standards and accreditation process. Your lab is required to keep track of the changes that affect labs because they are considered official once published in Perspectives. If your lab is part of a hospital, the CEO or administrator, medical staff director, and the laboratory manager each receive a complimentary copy of Perspectives as a value-added part of your accreditation fee. The laboratory manager’s name is taken directly from your organization’s e-App. Freestanding labs receive one copy that is sent to their CEO or administrator. If you are a lab manager at a Joint Commission-accredited laboratory and you are not receiving a copy of Perspectives, call your account rep at (630) 792-3007.
As of October 1, Quality Check includes a comprehensive directory of health care organizations. This list includes organizations that are Joint Commission accredited and organizations that are not accredited by The Joint Commission. This is the first listing of its kind.
In addition, Quality Check users can locate health care providers by the types of services they provide. The new “Search by Service” feature is in addition to the existing search by name and type of provider. The inventory of services on the Application for Survey has been expanded to support the Search by Service feature. An organization can update their inventory of services at any time by accessing The Joint Commission extranet.
Laboratory professionals around the world will be able to collaborate to develop performance improvement solutions through The Joint Commission’s WikiHealthCare™ application. Launched in June, this free, internet-based forum can be accessed through a link on The Joint Commission’s home page, or directly at wikihealthcare.jointcommission.org. Look in the next issue for an in-depth article on WikiHealthCare.
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Audio conferences
Audio conferences are an easy way for more employees to receive training right at your facility. The 90-minute conferences include 60 minutes of formal presentation followed by a Q&A. Sessions are held from 11:30 a.m. To 1:00 p.m., CT. The fee is $249 per connection.
- February 27: Laboratory - Understanding the Basics of Joint Commission Accreditation
- April 9: The Joint Commission Application Process - How to Get Started
Purchase these conferences as a pair and receive a 20 percent discount (total price for both audios $400).
E-tools
Accreditation Manager Plus: An Interactive Toolkit for Continuous Compliance™
This electronic tool arms your organization with everything it needs to maintain continuous compliance and prepare for the Periodic Performance Review. Choose from individual PC, network, web-based intranet, or web-based extranet versions.
Publications
2008 Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing
Order code: CLSM-08, $265
For registration information or to order, call Joint Commission Resources, Inc., toll-free at (877) 223-6866, 8 a.m. to 8 p.m. C.T., or go to www.jcrinc.com.
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- Laboratory Accreditation (630) 792-5287
- Standards Interpretation Group (630) 792-5900
- Laboratory Account Representative (630) 792-3007
- Customer Service (630) 792-5800
- Pricing Unit (630) 792-5115
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