Hosted by Medical Automation Systems

Click here for more 
HIPAA information 

FREE AACC JOB BANK

News Releases

Subwebs

WHAT'S NEW

ARTICLE WATCH

UPCOMING EVENTS

PUBLICATIONS

CONTACT US

REFERENCES

REGULATORY

TESTS

VENDORS

PROCEDURES

DEFINITIONS

CLINICAL TOPICS

LINKS

SUBWEBS

JCAHO Laboratory Accreditation FAQ (Lots of good Point of Care questions answered)

Overview

The Joint Commission on Accreditation of Healthcare Organizations was organized to improve the quality of healthcare for the public by providing accreditation and related services that support performance improvement in healthcare organizations. The Joint Commission is the nation’s oldest and largest standards-setting and health care accrediting body.

The Joint Commission began evaluating laboratory services for hospitals in 1979 and was granted deeming authority under the Clinical Laboratory Improvement Amendments of 1988(CLIA 88) in January of 1995. Laboratories that are accredited by the Joint Commission meet very rigorous quality standards.

Any laboratory may apply for a Joint Commission accreditation survey under the laboratory standards if the following requirements are met:

• The organization is in the United States or its territories, or is operated by the United States government or under a charter of the United States Congress, if outside the United States.
• The organization assesses and improves the quality of its services. The United States government or under a charter of the United States Congress, if outside the United States.
• The organization identifies the services it offers, indicating which it provides directly under contract or through some other arrangement.
• The organization provides services covered by the Joint Commission’s standards.

For the purposes of CLIA certification, laboratory testing is defined as analyzing a substance removed from the body and using this information for the diagnosis, prevention, or treatment of any disease, impairment, or assessment of the health of human beings.

CLIA requires that laboratory surveys be conducted every two years. This means that, if your laboratory is part of another Joint Commission accredited health care organization, your survey will not ordinarily take place at the same time as your health care organization’s triennial survey. Just like any other department, however, your laboratory will be reviewed under the leadership, improving organization performance and other standards contained in the applicable Joint Commission manual that serves as the basis for the triennial survey process.

An advantage of the laboratory survey process is that all laboratories within an organization can be reviewed during the course of one survey. The Joint Commission survey covers not only laboratories in the hospital, but also laboratories serving different organizational elements, even if services are provided off-campus or in a neighboring state. A separate application for each laboratory is not required.

In the future, look for more information about the JCAHO process and its standards for waived testing.

There are a large number of articles and other information on preparing for a laboratory inspection at the JCAHO website.  For a listing, click here.

Back to top