An Accreditation Surveyor’s View

October 2020 - Vol. 9 No. 9 - Page #4

Q&A with Barbara A. Schwarzer, MT(ASCP), MHA, MSOL, CPHQ
Field Director, Pathology & Clinical
Laboratory Services Accreditation Program
The Joint Commission


Medical Lab Management: How are Joint Commission surveyors engaging facilities for surveys and what can those facilities do to prepare for site visits?

Barbara A. Schwarzer: All laboratory surveyors have been trained in emergency management and infection control practices based on the Centers for Disease Control (CDC) guidelines. Surveyors will wear masks during the survey and maintain physical distancing of six feet from others. To help uphold these standards, laboratories are encouraged to use technology as much as possible. This includes projection of patient charts and documents presented on a large screen for review to avoid the close proximity of side-by-side document review. We want to convey up front that Joint Commission surveyors have been trained in communication sensitivity and we want to listen to and understand the challenges health care organizations are encountering during the COVID-19 public health emergency.

MLM: What are the primary focus areas for Joint Commission surveys at this point?

Schwarzer: During the survey, there will be a focus on emergency management and infection control processes. Close attention will be given to risks encountered and actions taken to mitigate such risks. While special attention may be paid to emergency management and infection control for obvious reasons, there are no new standards pursuant to COVID-19, and laboratories should be following the protocols already in place.

Furthermore, Centers for Medicare and Medicaid Services (CMS) did not issue any laboratory waivers specific to the pandemic. This means that all standards apply, including during the period of March 1, 2020 through the date that the health care organization states its readiness for survey. Prior to resuming surveys, Joint Commission account executives reached out to health care organizations to discuss their readiness for survey and these discussions are ongoing as the response to this coronavirus continues to evolve.

MLM: Prior to the COVID-19 pandemic, what were the notable areas of laboratory noncompliance with Joint Commission standards?

Schwarzer: In 2019, the most commonly cited standards include those that involve:

  1. Corrective action and attestation statements for proficiency testing
  2. Incomplete laboratory reports
  3. Correlations performed every six months
  4. Competency assessments, including all six elements, annual performance review, and semi-annual performance review for new employees
  5. Documentation and tracking of reagent lot numbers
  6. Monitoring temperature-controlled spaces
  7. Maintenance, inspection, and performance testing of instrumentation and equipment

MLM: What resources are available for laboratory leadership to assess its overall infection control and exposure risks?

Schwarzer: Resources are available to all Joint Commission accredited facilities and can be found on the Joint Commission website:

This is a regularly updated listing of resources, which includes information on PPE, ventilators and other respiratory support, staffing and telehealth, and specifics for the laboratory, such as quality control testing for COVID-19 tests and validation of COVID-19 tests. All accredited facilities are encouraged to interact with the Joint Commission’s resource library.

MLM: Depending on the predominant areas of noncompliance, can you share any examples of good, accredited practices that will benefit the laboratory and help them gain compliance?

Schwarzer: Certainly, there are nuances about each facility’s compliant or noncompliant practices, but all of the following will enhance safety and compliance for patient care:

  1. Strong, engaged leadership that exercises detail-oriented oversight
  2. An established culture of safety where employees feel safe in reporting errors and problems
  3. A well-documented competency program that completely covers the lab’s operations and is timely in its execution
  4. Collaboration with other departments where laboratory services extend, (eg, nursing for point-of-care testing and blood transfusions and respiratory therapy for blood gases)
  5. A well-organized proficiency testing program with documentation and follow up on proficiency testing failures

MLM: How can hospital laboratories best prepare for a Joint Commission survey in the near future?

Schwarzer: The best way to prepare for a survey is to review The Joint Commission standards as a laboratory team, including the laboratory medical director. Document the health care organization’s team efforts and connect and collaborate with other departments where laboratory testing is performed to develop a seamless, safe process. Mainly, be aware of what is taking place in your laboratories and use the process as an opportunity to improve.

MLM: How should a facility respond to an RFI after survey?

Schwarzer: Follow instructions on the final report for responding to the Request for Information (RFI) on the Survey Analysis for Evaluating Risk (SAFER) Matrix. The level of risk will determine the process and information required to respond to the RFI.

MLM: How can laboratory leaders engage with The Joint Commission and ensure accreditation compliance moving forward?

Schwarzer: Laboratories accredited by The Joint Commission have many resources available to them. Laboratory staff can send questions regarding standards compliance directly to The Joint Commission’s Standards Interpretation Group via its website. They can also contact their account executives for information regarding their laboratories’ application and can access updates regarding survey process and standards compliance via The Joint Commission’s monthly publication, Perspectives, all available at

Barbara A. Schwarzer, MT(ASCP), MHA, MSOL, CPHQ, is the field director in the pathology and clinical laboratory services accreditation program at The Joint Commission. She surveys the standards in the Comprehensive Accreditation Manual for pathology and clinical services. Prior to this, Barbara was the laboratory manager and quality and infection control manager at Aultman Orrville Hospital in Orrville, Ohio.


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