JCAHO Requirements for Laboratory Accreditation Record & Specimen Retention

Anatomic and medical pathology laboratories (e.g., laboratory medicine) directly affect a considerable amount of all clinical diagnoses in the United States. Laboratory workers and the work they do are vital to protect and preserve patient safety. To conduct business, laboratories require licensure and may also need accreditation. A laboratory's quality and safety issues regulation requires record keeping and retention specifications. Outstanding records are a sign of high quality. The Joint Commission on Accreditation of Health care Organizations (JCAHO) establishes the criterion by which to measure health care quality in the United States and worldwide.

JCAHO

• Since 1979, JCAHO has been appraising and accrediting hospital laboratory services and independent laboratories from 1995. Currently, JCAHO accredits approximately 2,000 businesses offering laboratory services. The Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing guides the survey process. These standards underscore the importance of laboratory services on the service delivery and caring processes that adds value and support to the entire health care organization.

Laboratory Accreditation Record

• The JCAHO Laboratory Accreditation Program requires the survey of all laboratories every two years. Thus, JCAHO requires two years of accreditation record keeping. The JCAHO standards require laboratories to enroll in a CMS-approved proficiency testing program for every regulated test the lab conducts. Laboratories must report proof of annual enrollment in a proficiency testing program to JCAHO each year. Additionally, JCAHO may want to review the minutes from professional staff meetings, records of continuing education and technical and professional staff training, safety training records and the information used to make professional staff member recommendation about re-credentialing.

Specimen Retention

• Although they are not written accounts, for specimens JCAHO requires two years of records for surgical pathology requests, laboratory service requests and other laboratory test request files. Two years of records of specimens received (tests, with patient identification, submitter's name, report and receipt dates, kind of test performed and their results, with original test information and instrument printouts or exact copy). Five years of records for cytology slides and immuno-hematology records. Ten years of records for histopathology slides, fine-needle aspiration slides and false-negative and false-positive results are required for each type of specimens.