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Monday 5:28 CST, March 19, 2018


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Accreditation and Certification

January 03, 2018

Now in effect: Change to requirements for credentialing, privileging of independent pathologists

JC_Online_Jan_optThe Joint Commission is no longer requiring hospitals, critical access hospitals or ambulatory care organizations to credential and privilege pathologists who provide diagnostic services through a reference (contract) laboratory. This change is effective immediately.

A reference laboratory is a laboratory contracted for testing that is owned and operated by an organization other than the organization referring the testing.

Clinical Laboratory Improvement Amendments (CLIA) regulations 42 CFR 493.1351 through 493.1495 outline specific and rigorous competency requirements for laboratory personnel, including requirements for pathology services and its subspecialties. But because pathologists practicing in the U.S. are required to comply with these requirements, Joint Commission-accredited organizations that seek the services of pathologists within independent reference laboratories (that comply with CLIA regulations) can safely presume that the pathologists are qualified and competent to perform all diagnostic services within their pathology practice — thus making an additional credentialing and privileging process unnecessary.

To reflect this change, the Introduction to Leadership (LD) Standard LD.04.03.09 — Laboratory services provided through contractual agreement are provided safely and effectively — now includes the following additional exception to the requirement that “each licensed independent practitioner providing services through a contractual agreement must be credentialed and privileged by the [organization] using his or her services,” that states:

  • Services provided by a pathologist through a contracted reference laboratory compliant with CLIA (Clinical Laboratory Improvement Amendments) regulations.

However, when the pathologist provides his or her professional service, including consultation in the same laboratory or organization where the specimen was collected or prepared, credentialing and privileging is required.

This change is reflected in the January 2018 E-dition®, as well as the 2018 print manuals for ambulatory care, critical access hospitals, and hospitals. (Questions: Ron Quicho,

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