The beginning of the year is a good time to make changes and this year marks a number of significant changes for us. After more than 19 years as the Joint Commission on Accreditation of Healthcare Organizations, we have shortened our name to The Joint Commission. This reflects not only common usage, but common sense. The name change signifies that we are moving beyond a traditional approach into a wider range of accreditation and certification products.
To go along with our new name, the logo has been updated and refreshed. The graphic contains four colored triangles representing the four elements of the cycle for performance improvement (plan, do, study, act). The four triangles form an arrow pointing upward to reflect The Joint Commission’s commitment to continuous improvement.
2007 promises to be a momentous year in other ways. We are currently working on a project with the Centers for Disease Control and Prevention to identify and develop best practices in laboratory medicine (see article). I will be participating on the subgroup focusing on proficiency testing. It’s exciting to be a part of this group that is working toward improving our field, and, ultimately, the care our patients receive. I’ll keep you posted on our progress.
Also, as noted in the article on this page, the e-mail addresses at The Joint Commission have changed. Mine is now mpeck@jointcommission.org. As always, please contact me with comments regarding our laboratory survey process.
Margaret Peck, MS, MT (ASCP)
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In January, The Joint Commission unveiled its new branding initiative with an abbreviated name and a newly redesigned logo. Specific changes include:
- The name has been shortened from the Joint Commission on Accreditation of Healthcare Organizations to The Joint Commission.
- New logos for The Joint Commission, Joint Commission Resources, Joint Commission International, and the International Center for Patient Safety.
- New Gold Seal of Approval™ and updated Publicity Kit.
- Website redesign.
- The “Jayco” extranet has been renamed “The Joint Commission Connect.” It is being redesigned and will launch in the second quarter of 2007.
- Lab Focus redesign.
- E-mail extensions have changed to "@jointcommission.org."
“These changes symbolize our ongoing commitment to achieve excellence in our daily work,” says Margaret Peck, director, Laboratory Accreditation Program. “They also acknowledge our broadening scope of services and products.”
Read more about the branding initiative.
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The Department of Health and Human Services’ Centers for Medicare & Medicaid Services has granted The Joint Commission continued deeming authority under the Clinical Laboratory Improvement Amendments of 1988.
The CMS designation means that laboratories accredited by The Joint Commission are “deemed” as meeting both CLIA and Medicare certification requirements. CMS found that the Joint Commission’s standards for laboratories are equal to, or more stringent than, the CLIA condition-level requirements.
The federal government’s Final Notice, granting the deeming authority for five years to The Joint Commission Laboratory Accreditation Program was published in the February 2007 Federal Register.
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During the tracer portion of the on-site survey, surveyors now have to the option to access records up to 24 months prior to the date of survey. This means that laboratory professionals should take steps to ensure that data and records for the past 24 months are readily available at the time of the full unannounced survey, including quality control, instrument maintenance and competency records.
“These new requirements will enhance our ability to provide a comprehensive and consistent laboratory survey process,” explains Margaret Peck, director. “It provides a more complete picture when reviewing periodic activities, such as annual competency assessments and policy review, semiannual correlations, calibration verification and verification of non-regulated analytes.”
At the beginning of the survey, surveyors will randomly select patients from the previous 24 months in each specialty and subspecialty. For the tracers, surveyors will choose patients who have received laboratory services from within each of the following three timeframes:
- Less than 6 months
- 6–11 months
- 12–24 months
For example, the surveyor may review hematology testing for one or more patients selected randomly from each of the three timeframes. The surveyor will concurrently review the testing for that specialty or subspecialty, so survey length will not be affected. For more information, see the January 2007 issue of The Joint Commission Perspectives.
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The latest health care trends affecting laboratories, issues related to CLIA, and new Joint Commission initiatives were among the topics covered at the Annual Invitational Surveyor Training Conference held in January.
“Every year we bring in our surveyors from all across the country for an full week of training,” says Margaret Peck, director, Laboratory Accreditation Program. “It’s one of the many ways we offer on-going education, which enhances surveyor consistency during the laboratory survey process.”
The week-long training conference offers plenary sessions with general Joint Commission topics and lab-specific breakout sessions. Some of the lab-specific sessions included:
- Modified patient tracer methodology to cover the 24-month track record
- Calibration verification for automated cell counters
- National Patient Safety Goals compliance
Nancy J. Cacciatore-Huber, MT (ASCP), a lab surveyor for 11 years, appreciates the annual get-together. “It’s a challenging and enlightening week. The continuing education improves our skills, which makes us better surveyors. One aspect of our education was focused on integrating lab survey findings into a systems overview,” says Cacciatore-Huber. “Ultimately, this type of training improves the product that we’re offering our customers.”
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Margaret Peck, director, Laboratory Accreditation Program, and Linda Hanold, director, Performance Measurement and Health Information, are serving on subcommittees of a project undertaken by the Centers for Disease Control and Prevention. The overall goal of the project is to enhance the practice of laboratory medicine by identifying ways to improve laboratory testing and services. The project encompasses:
- Development of a report describing the current state of the field of laboratory medicine.
- Development of a process to define, identify, categorize and evaluate best practices and policies in laboratory medicine and the settings in which they apply.
- Evaluation of the effectiveness of proficiency testing programs in the United States to meet quality improvement, educational and regulatory goals for clinical laboratories.
Battelle Memorial Institute, Columbus, Ohio, will carry out the project under contract to the CDC. Work on all three project components is expected to be finished in September 2007.
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The Joint Commission has approved new and revised requirements addressing molecular testing effective July 1, 2007. The changes include:
- New standards QC.18.10 through QC.18.70
- An additional bullet at standard IM.6.190, Element of Performance 3
- The addition of EP 9 to Standard LD.2.140
For the complete text, see the January 2007 edition of The Joint Commission Perspectives.
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Joint Commission representatives attend laboratory conventions throughout the year. Stop by and see us at the following meetings:
- CLMA ThinkLab, March 24-27, Houston, Texas
- American Association of Clinical Chemistry, July 15-19, San Diego, Calif.
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Join us at a Joint Commission reception to be held at the annual CLMA conference in Houston, Texas, on March 26. The reception follows the presentation entitled, “New Directions for Laboratory Accreditation Surveys: A Major Hospital’s Experience with Joint Commission Accreditation Approaches,” given by Dr. Patricia Charache, MD, Johns Hopkins Medical Institutions. For more information and to receive an invitation, contact Beth Badon, marketing manager, at bbadon@jointcommission.org.
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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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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/Infomart.htm.
Education
Accreditation Essentials: Laboratories
This one-day, advanced program focuses on the accreditation process and standards, CLIA regulations, revisions to waived testing standards, new infection control standards, compliance strategies and National Patient Safety Goals.
- July 14, San Diego, Calif.
- Nov. 9, Oakbrook Terrace, Ill.
Publications
Accreditation Process Guide for Laboratories
A comprehensive, user-friendly source guide designed to help laboratories understand the Joint Commission accreditation process.
Order code: APGL05SJ, $80
From Practice to Paper: Documentation for Laboratories
Learn how to make sure your documents are capturing the information your laboratory needs to comply with the standards and improve the quality of services.
Order code: SDFL01SJ, $55
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