The Joint Commission Laboratory Program- What’s New. Jennifer Rhamy Executive Director . What’s New at The Joint Commission. Me- and excited to be working with all of you Lab STAT News monthly emails Recent customer survey to hear voice of the customer
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CMS Requirements—may include multiple CMS areas
Joint Commission EP
use these colors
Test Menu and Instruments Used
Tests that you perform in your laboratory
Total Test Volume for each CLIA
ABG =1 procedure
pH, pCO2, pO2 = 3 tests
For all laboratory services provided on-site.
Environmental and Safety Inspections
Safety Committee Reports
Hazardous Waste Disposal Manifests
Infection Control Policy and Processes
Data analysis and conclusions
Proficiency Testing for last 6 events
Copies (hard copy or electronic) of original test performance
Procedure for handling and assessing PT
Attestation signed by testing personnel
Review of PT results from vendor
Investigation and corrective action of all unacceptable results.
Policy and Procedures
Do not need to move to a central location
Quality Control Data
Last 24 months accessible
Calibration and Calibration Verification
Performance over last 24 months accessible
Last 24 months accessible
Have someone available who knows HR file system.
Validation of educational requirements
State licenses as applicable
Competency Assessment Records
Current and last annual assessment
Patient tracers cover all specialties and subspecialties across the period from the last full survey
May be less than 24 months.
Labs converting from another accreditor
are reviewed for prior four months activity, except for PT which is for 24 months.
Know how to access information.
If on paper, how to retrieve if
information is in storage
If electronic, what program(s) will
you need to access for historic data
If using EMR, who will be needed to access patient information
Encourage staff to openly participate.
If staff doesn’t understand what the surveyor wants, ask the surveyor to explain in more detail.
If staff doesn’t know the answer to a question, it’s okay to say they don’t.
Tell the surveyor how your lab complies with standard within your lab.
Every lab doesn’t comply the same way.
Have open discussion about standards.
Inform all staff that they will be asked to participate in survey.
Inform all staff of same information that will be required for their survey activity.
Let the surveyor know who might be available only on certain days.
Megan E. Sawchuk, MT(ASCP)
Associate Director, Standards Interpretation Group
*Use of Option 1 or 2 requirements exceeds the standards.
Centers for Medicare and Medicaid Services (CMS)
Centers for Disease Control and Prevention (CDC)
Food and Drug Administration CLIA Database Search
The Joint Commission’s
Frequently Asked Questions (FAQs)