The Joint Commission clarifies key compliance issues

April 1, 2010

Laboratories provide complex services that are essential
to diagnosis and treatment of patients. Laboratories — along with
organizations such as the Centers for Medicare and Medicaid Services (CMS)
and The Joint Commission — want better patient outcomes and, therefore, are
concerned about improving the safety and quality of laboratory services.

The Joint Commission has been evaluating and accrediting
hospital laboratory services since 1979 and freestanding laboratories since
1995. Today, The Joint Commission accredits almost 2,000 organizations
providing laboratory services. This represents almost 3,000 Clinical
Laboratory Improvement Amendment (CLIA)-certified laboratories, including
freestanding facilities, such as reference labs, in vitro
fertilization labs, and those connected with other healthcare organizations
such as ambulatory surgical centers and long-term care facilities.

Some Joint Commission compliance issues show several
areas that are worthy of attention by labs as part of efforts to improve
safety and quality. The most common areas surveyors cite as “not compliant”
include National Patient Safety Goals (NPSG), proficiency testing (PT), and
effective leadership. Two frequently cited NPSGs include:

NPSG 01.01.01 – Improve the accuracy of patient
Use at least two patient identifiers. The reasons for
compliance failures include the fact that multiple individuals and
departments are typically involved in specimen collections, as well as staff
who did not understand or did not comply with the organization’s policies.
Another factor for non-compliance with the requirement is staffing
shortfalls that result in shortcuts in the identification process. To ensure
consistent patient-identification practices, consider the following

  • Conduct audits, using interviews and observations, to
    guard against deviations from organization policy.
  • When a deviation is identified, implement corrective
    actions and follow up to ensure behavior has changed.

Recent refinements to the goal to improve the accuracy of
patient identification have received attention, including a January 2010
“Washington Report” column. Although the goal required labs to
actively involve the patient in this identification step whenever
, feedback revealed that separating the “whenever possible” was
difficult to track and trend. In other words, the requirement as written
lacked enforceability and did not adequately address managing patients who
are not able to participate in the identification process. As a result, The
Joint Commission deleted this element of performance for the goal.

The Joint Commission continues
to support active patient involvement in the identification process as a
best practice …

Active patient involvement is a best practice for
patient identification, and the deletion of the element of performance from
the goal is not intended to discourage use of active patient involvement or
minimize its value. Another element of performance from this same goal still
requires labeling in the presence of the patient. Some customers mistakenly
believed this requirement was proposed for removal; it has not been removed
from accreditation requirements. The Joint Commission continues to support
active patient involvement in the identification process as a best practice
and encourages organizations to use such an approach when it is reasonable
to do so.

NPSG 02.03.01 – Report critical results of tests and
diagnostic procedures on a timely basis.
Measure, assess, and, if
appropriate, take action to improve the timeliness of reporting and
timeliness of receipt by the responsible licensed caregiver of critical
tests, critical results, and values.

The result sought from this requirement is that
critically abnormal test results are communicated quickly to a responsible
licensed independent caregiver so prompt action can be taken. To comply with
this goal, identify critical tests for which any result should be reported,
and work with leaders in other departments to ensure that when the lab calls
to report results to a patient-care unit, the result is quickly communicated
to the responsible licensed caregiver. More information about complying with
this goal is available at

In addition, examining compliance with the following
accreditation standards can provide opportunities for improvement:

Standard QC.1.20.PT services used for specialty
and subspecialty equal or exceed applicable laws and regulations with
respect to variety and frequency of testing and satisfactory performance

Standard QC.1.30.The laboratory maintains a
cumulative record of participation in a PT program.

Standard WT.1.60.Quality control and test result
records are maintained (for waived tests).

Standard QC.5.300.The lab uses standardized
procedures to acquire, receive, store, and issue tissues.

Standard EC.6.20.Lab equipment is maintained,
tested, and inspected.

Standard IM.6.20.The lab report includes the
date and time of reporting and the condition of any unsatisfactory

Standard LD.2.60.The directorship of the lab is

At its core, accreditation is a risk-reduction activity, which
increases the likelihood that patients will experience good outcomes.
The Joint Commission remains committed to working with laboratories to
continuously improve healthcare and provide safe and effective care of
the highest quality and value.

Marilyn Sims, MT(ASCP), has extensive experience in laboratory management and with Joint Commission standards and survey processes as a former surveyor and member of the Standards Interpretation Group. She is currently a laboratory consultant for Joint Commission Resources.

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