CLARIFICATION: Approved Laboratory Services in a …

1 When Laboratory testing is provided in a joint commission accredited organization, the organization must have aClinical Laboratory Improvement Amendments of 1988(CLIA 88) certificate that is appropriate for the testing per-formed there. In addition, if the testing is categorized by theFood and Drug Administration (FDA) as nonwaived, thetesting must be accredited by The joint commission sLaboratory accreditation Program or one of the cooperativepartners of The joint commission . These partners includethe College of American Pathologists (CAP), cola , and theAmerican Society of Histocompatibility and Immunology(ASHI). With the exception of the state of Washington, stateinspection does not negate the requirement for accreditationby The joint commission or one of the cooperative requirement is described at the beginning of TheAccreditation Process (ACC) chapter of The JointCommission s comprehensive accreditation manuals, in boththe Scope of accreditation Surveys and the TailoredSurvey Policy indicated in the ACC chapter, The JointCommission evaluates all health care Services provided by theorganization for which The joint commission has standardsand makes an accreditation decision for each accreditationprogram surveyed.

2 In addition, because the Centers forMedicare & Medicaid Services (CMS) considers them to bean essential service of the hospital, Laboratory Services areregarded as part of the entire organization s compliance statusfor accreditation . Consequently, joint commission policy isthat all Services must be accredited to maintain the same levelof service delivery throughout the nonwaived Laboratory testing is not accredited asdescribed above, decision rule FOC01 (in the AccreditationDecision Rules section of the ACC chapter) applies. Thisrule requires documentation of successfulaccreditation, whichcan be verified with an accreditation decision letter from therelevant accreditation organization or with other documentsthat state the Laboratory has been awarded accreditation ingood standing.

3 If a Laboratory cannot demonstrate thisachievement, The joint commission will perform a laborato-ry survey within one you have any questions about whether your laboratoryservices comply with the tailored survey policy described inthe ACC chapter (and shown in the box below), please con-tact your account executive at 630-792-5900. PCLARIFICATION: Approved Laboratory Servicesin a joint commission Accredited PrimaryProgramAPPLICABLE TOALLPROGRAMST ailored Survey PolicyThe public expects all of the programs or Services deliveredunder the auspices of an accredited organization to havebeen evaluated. As such, The joint commission applies itsTailored Survey Policy to components (for which there areapplicable joint commission standards) that are organiza-tionally and functionally integrated with the health careorganization applying for accreditation (see Organizationaland Functional Integration [in the ACC chapter]).

4 The joint commission will include another service, pro-gram, or related entity (that is, component), whether provid-ing programs or Services directly or through a contractualarrangement, in the survey of the applicant organizationunder the following circumstances: There are joint commission standards applicable to thecomponent There is organizational and functional integrationbetween the component and the applicant organizationThe joint commission survey, assuming satisfactorycompliance, provides one accreditation award for eachaccreditation program surveyed (for example, ambulatory,home care, long term care, and so forth).Note:Any service, program, or related entity that is acomponent of an accreditation -eligible organization mayindependently seek accreditation if it can meet JointCommission survey eligibility requirements.

5 The results ofsuch a separate accreditation survey will not affect the over-all organization s Publication of joint commission RequirementsTailored Survey PolicyPage 4 joint commission Perspectives , April 2012, Volume 32, Issue 4 Copyright 2012 joint commission on accreditation of Healthcare Organizations