CLIA regulations require that your laboratory enroll in a Centers for Medicare and Medicaid Services (CMS) approved proficiency testing (PT) program for all regulated tests that you perform. Once a year, the Joint Commission requires you to submit documentation attesting to your enrollment in PT. This documentation should be submitted during November and December of the current year to verify enrollment for the upcoming year.
For more information see the following:
For questions regarding the requirement to submit documentation of annual enrollment in proficiency testing, please call (630)792-5085 or e-mail the Joint Commission at oryx@jointcommission.org.
Proficiency Testing Monitoring
Both CLIA and the Joint Commission require you to maintain successful performance on PT. The Joint Commission receives unsuccessful proficiency testing performance data from CMS through an electronic communication link. Unsuccessful performance is defined as a failure to achieve satisfactory performance for two consecutive or two out of three consecutive testing events.
The following are considered unsuccessful proficiency testing performance:
- Failure to attain a score of at least 80% for all specialties, subspecialties, or tests, except ABO group and D (Rho) typing and compatibility testing for two consecutive or two out of three consecutive testing events.
- Failure to attain a score of at least 100% for ABO group and D (Rho) typing or compatibility testing for two consecutive or two out of three consecutive testing events.
When unsuccessful proficiency testing occurs, the Laboratory Performance Measurement Analyst at the Joint Commission will notify the laboratory directly. This Medical Technologist will work with you to resolve the PT problem through corrective action. Laboratories may be asked to submit information that could include the following:
- Current and historical PT reports
- Quality control and equipment monitoring
- Analysis and corrective action of the problem that caused the failure
- Steps taken to assure the reliability of patient test results
If the problem cannot be resolved, the laboratory may voluntarily cease performing the test and notify the Laboratory Performance Measurement Analyst at the Joint Commission in writing. If the problem cannot be resolved and the laboratory decides to cease performing the test, the resumption of the testing will require notification to the Laboratory Performance Measurement Analyst at the Joint Commission and evidence of satisfactory performance on two sequential, successful testing events. The evidence may include additional proficiency testing or other comparison of results. For extreme problems or those that jeopardize patient safety, we may conduct an on-site review that may ultimately affect your accreditation status.
For questions or notifications regarding unsuccessful proficiency testing and submission of corrective plans of action, please contact the Laboratory Performance Measurement Analyst by phone at (630)792-5248, via e-mail estawczyk@jointcommission.org, or in writing at Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Boulevard, Oakbrook Terrace, IL 60181.