Hospital executives are always looking for ways to improve efficiency within their facilities. One obvious method is to choose Joint Commission accreditation for both your laboratory and your hospital. Using a single accrediting body can give you an advantage over your competitors and benefit your organization in a number of ways, including:
- Optimizes workflow because the entire organization is working from the same core standards. This makes the survey process more relevant to all departments in the hospital.
- Strengthens relationships between the lab and other hospital departments, which enhances communications for better patient outcomes.
- Changes the culture so that the lab is viewed as an integral part of the clinical services team.
If you’d like to hear more about the advantages of Joint Commission laboratory accreditation, or if you’d like me to visit your facility and give you a personal overview of the benefits of Joint Commission laboratory accreditation, please contact me at mpeck@jointcommission.org or call (630) 792-5287.
Margaret Peck, MS, MT (ASCP)
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PPMP competency assessments required for physicians
Beginning Jan. 1, 2007, annual competency assessments are now required for licensed independent practitioners who perform Provider Performed Microscopy Procedures. This standards revision was made to ensure that the standards meet or exceed current federal CLIA regulations for moderate complexity testing.
“To simplify annual competency assessment for PPMP, laboratories could combine it with their existing semiannual verification process,” explains Megan Sawchuk, associate director, Standards Interpretation Group. “Both requirements could be easily met by using either proficiency testing or a similarly designed process, as outlined in Standard QC.1.60.
“For example, a hospital with a large medical staff may choose to use a web-based competency assessment tool. Individual physicians would only need to participate once a year for competency purposes,” Sawchuk explains. “And, if you break the physicians into two groups and each group participated in alternating six month intervals, that would satisfy the annual and semiannual requirements.
“For non-instrument based waived tests, such as occult blood, you may continue to use either annual competency assessment or the credentialing and privileging process if the testing is within the physician's scope of practice,” says Sawchuk.
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Last year, the top 10 standards areas out of compliance were:
QC.1.30 (25% non-compliant) The laboratory maintains a cumulative record of participation in a proficiency testing program.
WT.1.10 (19%) The organization establishes policies and procedures that define the context in which waived test results are used in patient care, treatment, and services.
Goal 2 (19%) Improve the effectiveness of communication among caregivers.
QC.1.50 (16%) The laboratory’s performance on proficiency testing is maintained at an acceptable level.
WT.1.60 (16%) Appropriate quality control and test records are maintained.
LD.2.60 (15%) The directorship of the laboratory is effective.
QC.1.60 (14%) The laboratory uses a system for verifying the accuracy and reliability of results obtained for tests not requiring proficiency testing by law.
Goal 1 (14%) Improve the accuracy of patient identification.
QC.5.300 (14%) The laboratory uses standardized procedures to acquire, receive, store, and issue tissues.
EC.6.20 (13%) Laboratory equipment is maintained, tested, and inspected.
For information on complying with Joint Commission requirements, see the next article or visit the FAQs on the Joint Commission website. If your question is not addressed, contact the Standards Interpretation Group through its online question form or by calling (630) 792-5900.
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CLIA regulations require that your laboratory enroll in a Centers for Medicare & Medicaid Services approved Proficiency Testing program for all regulated tests that you perform. When unsuccessful proficiency testing occurs, Eileen Stawczyk, Laboratory Performance Measurement Analyst, will notify your laboratory directly and will work with you to resolve the problem. Following are some Frequently Asked Questions about PT.
Q. When should I submit a Plan of Action to The Joint Commission to address unsuccessful proficiency testing?
A. If your lab has unsatisfactory performance (less than 80 percent for most analytes) on two out of three consecutive proficiency testing events, this information will be transmitted to CMS by the PT provider. The Joint Commission will then send a letter requesting a POA within 10 days.
Q. Are there regulated analytes which require 100 percent compliance with proficiency testing to be considered satisfactory performance?
A. Yes. ABO, Rh, and compatibility testing require 100 percent compliance with each test event to be considered satisfactory performance.
Q. I’ve noticed that my proficiency test provider scores bacteriology analytes in the aggregate. If I have two consecutive proficiency test events with unsatisfactory analytes less than 80 percent (for example, a gram stain), yet my overall bacteriology score is still 80 percent or greater for both events, will I be expected to provide a POA?
A. Generally, no. Bacteriology is scored at the sub-specialty level, not at the analyte level. This type of scoring also applies to analytes found in parasitology, mycology, virology and mycobacteriology. Because The Joint Commission does not receive information specific to one unsuccessful gram stain proficiency test from the CMS database, a POA would not be requested. However, The Joint Commission would still require the laboratory to document and retain remedial action as indicated in QC.1.30, EP 4 and EP 5.
Q. What if a surveyor finds that my laboratory has had cumulative unsuccessful performance for one bacteriology analyte (such as a gram stain or organism identification)?
A. If the surveyor makes a finding during the survey, elements of a POA would have to be submitted through the Evidence of Standards Compliance process. As noted in the previous question, you will not receive a letter requesting a POA, nor would you submit a POA to the Laboratory Performance Measurement Analyst.
Q. Can The Joint Commission help me formulate the POA?
A. Yes. Contact Eileen Stawczyk by phone at (630) 792-5248, or via e-mail to estawczyk@jointcommission.org.
For more information about proficiency testing requirements, visit The Joint Commission website.
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Effective immediately, The Joint Commission has approved a new process for those laboratories that do not have the required Clinical Laboratory Improvement Act Certificate of Waiver at the time of survey, but receive one before the Accreditation Committee considers its accreditation decision. The process is:
- If at the time of survey a laboratory does not have the CLIA Certificate of Waiver, the Joint Commission will initiate an action for Preliminary Denial of Accreditation.
- The laboratory will be notified that if it obtains the required CLIA Certificate of Waiver before the Accreditation Committee’s consideration of its accreditation status, a recommendation for Accreditation will be made.
Note: If a decision of Preliminary Denial of Accreditation or Conditional Accreditation is recommended for reasons other than the missing CLIA certificate, the recommended decision will remain.
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If your organization seeks laboratory accreditation through another accrediting body, your organization must receive that body’s official accreditation decision before your Joint Commission lab accreditation expires.
The Joint Commission does not accept:
- A request for enrollment in or application to a recognized laboratory accrediting body.
- A state CLIA inspection in any moderate- or high-complexity laboratory testing.
If there is a possible lapse in accreditation, the Joint Commission will schedule an on-site laboratory survey to renew the existing accreditation for a period of two years. If the new accrediting organization’s official accreditation decision is in place before the start of the scheduled Joint Commission survey, the Joint Commission survey will be cancelled.
If your lab receives an adverse outcome from the other accrediting organization’s on-site survey, a Joint Commission on-site survey may be necessary. For more information, contact your account rep at (630) 792-3007.
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Tissue Storage and Issuance Standard FAQs have been posted online. Read everything you want to know about:
- Applicability of the Tissue Storage and Issuance Standards
- Autologous Bone Flaps
- Responsibility and Oversight
- Tissue Source Facilities―Verification of Licensing and Registration
- Temperature Recording, Monitoring, Alarms and Back-up Storage
- Verifying the Package upon Receipt
- Tissue Redistribution to Another Health Care Facility
- Traceability of Records
- Adverse Tissue Reaction Policies
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Joint Commission representatives attend laboratory conventions throughout the year. Stop by and see us at the American Association of Clinical Chemistry, San Diego, Calif., July 15-19.
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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 http://www.jcrinc.com/
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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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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