Alleviate Your Accreditation Anxieties through Collaborative Lab Surveys

Harriet Briggs, MBA, MT(ASCP), is the field director for The Joint Commission’s Laboratory Accreditation Program. She has 12 years of experience in laboratory quality assurance, including as the corporate laboratory manager at Prime Healthcare in Ontario, as well as the laboratory administrative director at Hunt Regional Healthcare in Greenville, Texas.

What major concerns do labs have about the accreditation process? How does The Joint Commission (TJC) alleviate those concerns?

First, many labs don’t feel ready for a survey. To alleviate this feeling, TJC surveyors and resources help labs shift their preparation approach. For example, instead of performing a time-consuming complete mock survey, labs can break down the process into smaller pieces that can be accomplished in a shorter time.

Second, most labs know their areas of compliance versus improvement, but they worry about unknown risks: what will the surveyor find during a survey? Our survey process is collaborative and educational. Survey findings help identify and mitigate unknown risks.

Third, many labs can be uncertain about how to interpret or comply with TJC standards. This is especially true for new customers and labs with new leadership, as they may be unfamiliar with the process, but again, TJC offers many resources.

What specific survey preparation resources does TJC offer?

There are many resources available to labs through TJC:

The TJC extranet site, available to each organization, has the accreditation manual containing TJC standards, and lab tools and resources for survey preparation.
Our website, www.jointcommission.org, hosts frequently asked questions, free webinars, and other resources.
Our TJC Standard Interpretation Group consists of expert surveyors that offer unbiased answers to lab and surveyor questions about how to interpret specific TJC lab standards.
A dedicated account executive assigned to each lab that can help answer your questions.

What makes TJC survey unique for clinical labs undergoing accreditation?

While many labs can be self-sufficient within a larger organization, our accreditation process promotes collaboration between labs and other departments, because we recognize this is better for patient care. We use our tracer methodology, which tracks a test result from when it’s ordered to when it’s entered into a patient's medical record, allowing us to review processes at various functional points along the way.

TJC lab standards are also written in a way that allows a lab medical director to customize the process and practices to their specific lab and patient population. This flexibility can make it difficult to interpret standards at first glance, but our TJC Standard Interpretation Group can help with that.

Lastly, our surveyors are highly knowledgeable and approach the survey in a collaborative way where they want to share their wealth of experience.

How does your team make a difference for laboratorians and laboratories?

We receive many testimonials from the labs we survey that emphasize the uniqueness of TJC’s survey process: collaborative, flexible, educational, and transformative. Our full time surveyors, who held lab positions as scientists or lab leaders prior to joining TJC, conduct at least 60 surveys a year. Therefore, they are eager to share their experience navigating lab practices and processes during the survey to help labs identify where they can improve to best support patient care.