TJC Changes Credentialing, Privileging Requirements for Independent Pathologists

PUBLISHED: Jan 4, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals

The Joint Commission (TJC) has announced that, effective immediately, hospitals, critical access hospitals and ambulatory care organizations are no longer required to credential and privilege pathologists who provide diagnostic services through a reference (sometime called “contract”) laboratory.

Joint Commission defines a reference laboratory as “…a laboratory contracted for testing that is owned and operated by an organization other than the organization referring the testing.”

Centers for Medicare and Medicaid Services (CMS) 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.

According to TJC, “…because pathologists practicing in the U.S. are required to comply with [CLIA] 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.”

TJC Leadership (LD) Standard LD.04.03.09 is revised to include an 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…” The revision requires that for any services provided by a pathologist through a contracted reference laboratory the laboratory must be compliant with CLIA (Clinical Laboratory Improvement Amendments) regulations.

Organizations should note that when a 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.

Included with today’s notice are example policies related to the above described change.

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