Written by: Mediware Consulting and Analytics on Monday, January 10, 2011 Posted in: Blood Management

The Joint Commission (TJC) has been evaluating and accrediting hospital laboratory services since 1979 and freestanding laboratories since 1995.

Today, approximately 3,000 clinical laboratories have earned TJC accreditation and the Gold Seal of Approval™. In compliance with CLIA regulations, Joint Commission standards address processes from laboratory specimen collection through analysis to result reporting. The Joint Commission’s stated objectives of the laboratory survey include evaluation, education and “‘good practice’ guidance that will help staff continually improve the laboratory’s performance.”

The laboratory survey evaluates patient care processes using the tracer methodology. The Laboratory Tracer is a unique way for The Joint Commission laboratory accreditation program to look at test results in the context of the surrounding systems not only within the laboratory, but also in other departments including patient records. The survey’s systemic approach strives to assess the performance of interconnected events and departments, and the impact of performance on patient care. Transfusion services and blood administration are an excellent example of how laboratory processes and adverse clinical events can be evaluated to determine if process issues exist within the organization and drive collaborative process improvement efforts. Joint Commission standards require laboratory oversight for blood administration training and policies, stating that other policies cannot conflict with the laboratory’s role.

A suspected RBC transfusion reaction is the subject of The Laboratory Tracer published in Tracer Methodology 101 from The Joint Commission. The surveyor conducting the tracer began by reviewing the medical record to assess the transfusion documentation and to identify the involved care providers. The surveyor questioned nurses about the transfusion process, patient assessment and transfusion reaction recognition and response. In the laboratory the surveyor reviewed quality control procedures for each instrument used for that patient: the patient had a BMP and CBC in addition to the transfusion. The surveyor also spoke with the technicians who performed the tests and investigated the adverse event. As recommended by The Joint Commission, mock tracers are an excellent way for multidisciplinary teams to review processes to identify gaps or potential missteps.

The Joint Commission has updated and revised its laboratory standards for 2011 including an expansion of the transfusion service standards.