Joint Commission Changes Two Laboratory Standards

PUBLISHED: Oct 7, 2016

In April 2016, the Centers for Medicare and Medicaid Services (CMS) issued a policy clarification about acceptable control materials used when quality control (QC) is performed in laboratories. TJC has now announced two changes to accreditation policies for laboratories that are designed to align with the CMS guidance.

  • QSA 02.09.01, Elements of Performance (EPs) 1 and 2 clarify that, “…using onboard controls is allowed as long as the QC specimens follow the same physical pathway as a patient specimen.”

Note: Laboratories are reminded that they must be able to demonstrate and show records instrument manuals and manufacturer’s instructions.

  • HR.01.02.05, Element of Performance 3 clarifies that “…there is no need to have paper copies of diplomas/transcripts in addition to the Primary Source Verification report.

Note: “Verifies and documents” in EP 3 means that organization need to provide a documented verification of education and experience.

For more information please see TJCs announcement about the changes.

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