Introduction

Introduction: How Joint
Commission Accreditation Can

Help on the Road to High
Reliability (INTRO)
High reliability in health care means maintaining consistently strong levels of safety and
quality over time and across all health care services and settings. High reliability
organizations operate in complex, high-hazard domains for extended periods without
serious accidents or catastrophic failures. Beginning a high reliability journey can feel
overwhelming—but it doesn’t have to be. Working with the right partner can help
optimize focus and create a more productive experience. Joint Commission accreditation
represents a critical step in any health care organization’s ongoing journey toward zero
harm through high reliability. It provides tools and best practice benchmarks to help
sustain and elevate the quality and safety of care, treatment, and services provided.
This “Introduction: How Joint Commission Accreditation Can Help on the Road to
High Reliability” (INTRO) chapter is an introduction to Joint Commission accredita-
tion and a user’s guide to understanding how the Comprehensive Accreditation Manual
for Laboratory and Point-of-Care Testing (CAMLAB) and its E-dition® counterpart are
organized. (E-dition is a web-based and fully searchable electronic manual accessible
through your program’s Joint Commission Connect® extranet site.)
There are four parts in this introduction to guide you toward compliance and support
your journey to high reliability:
1. Part I provides a brief overview of the value of Joint Commission accreditation and
the Laboratory Accreditation Program.
2. Part II explains the organization and content of the CAMLAB.
3. Part III explains how you can use the CAMLAB to successfully achieve and maintain
compliance with Joint Commission standards. Part III also provides tips and
strategies for finding the information you need to stay current with Joint
Commission standards and understand the survey process.
4. Part IV provides a comprehensive list of contacts and resources you can use to get
more information at The Joint Commission and Joint Commission Resources.
Shading indicates a change effective July 1, 2024, unless otherwise noted in the What's New.
CAMLAB Update 1, July 2024 INTRO – 1
E-dition July 1, 2024, Release
◤Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing
Read this chapter first to understand the Laboratory Accreditation Program and the
structure and content of the CAMLAB. After you have a better understanding of the
value of accreditation in improving and maintaining the quality of care, treatment, or
services, maximizing patient safety, and stimulating performance improvement, read
“The Accreditation Process” (ACC) chapter to understand The Joint Commission’s
accreditation process, including eligibility for accreditation; the application process;
accreditation surveys and what to expect before, during, after, and between surveys;
accreditation decision rules; and review and appeal procedures.
I. Introduction to Joint Commission

Accreditation
The Value of Joint Commission Accreditation
The Joint Commission’s Gold Seal of Approval® is a widely recognized benchmark
representing the most comprehensive evaluation process in the health care industry.
Joint Commission accreditation benefits your organization in the following ways:
■ Gives you a competitive advantage: Achieving accreditation is a visible demonstration
to patients and the community that your laboratory is committed to providing the
highest-quality services. It also sets you apart from other laboratories offering the
same types of care, treatment, or services.
■ Assists with recognition from insurers, associations, and other third parties: Some
payers, state regulatory agencies, government agencies, and managed care contrac-
tors require Joint Commission accreditation for reimbursement, for certification or
licensure, and as a key element of their participation agreements and reimbursement
practices.
■ Helps organize and strengthen performance improvement efforts: Accreditation
encompasses state-of-the-art performance improvement concepts that help you
continuously improve quality and standardize your processes of care, treatment, or
services.
■ Helps health care organizations become high reliability organizations: The Joint
Commission offers numerous resources and information to help laboratories move
toward high reliability—that is, to consistently perform at high levels of quality and
safety across all services and to maintain these levels over long periods. These
resources help leaders commit to high reliability by making it a priority, establishing
a safety culture throughout the organization that emphasizes trust and the reporting
of unsafe conditions and opportunities for improvement.
INTRO – 2 CAMLAB Update 1, July 2024
Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability ◥
■ Enhances staff education: The accreditation process is designed to be educational.

Joint Commission surveyors share best practice approaches and strategies that may
help your laboratory better meet the intent of the standards and, more important,
improve performance of day-to-day operations.
■ Provides access to experts in quality and safety: The Joint Commission is committed
to helping your laboratory move toward high reliability in your organization.
Through The Joint Commission, your laboratory has access to a range of
professionals eager to see you succeed. It starts with the assignment of an account
executive specializing in laboratories to help in day-to-day accreditation activities.
You also have ready access to the clinical and engineering experts in our Standards
Interpretation Group (SIG) as well as professional surveyors who visit your
organization for surveys and clinicians who are available to help provide expert
analysis of sentinel events in the Office of Quality and Patient Safety.
Figure 1 illustrates how Joint Commission accreditation guides laboratories in achieving,
maintaining, and demonstrating consistent excellence in quality and safety. Part III of
this chapter (Steps to Achieving and Maintaining Compliance) provides additional detail
on other tools and resources available to accredited organizations.
Achieve, Maintain, and Demonstrate Consistent Excellence

An Overview of the Joint Commission’s Accreditation and Specialty Certification Process
Nationally Recognized Standards On- and Off-Site Evaluations

• Enhanced requirements address critical patient • Patient/resident and system tracers proactively
safety and overall quality issues, including staff identify risks and high-performing areas.
competency, quality control, the testing • Experienced surveyors share leading practices and
environment, equipment, and pre- and insights to help you address challenging areas.
post-analytics. • Survey provides a collaborative learning
• Process-focused elements of performance environment for leaders and staff.
provide a comprehensive foundation for
quality and safety. Standards Evaluations
Achieve
Tools and Resources Intracycle Monitoring

• Survey Activity Guide outlines the • Intracycle Monitoring process guides
activities of a survey and helps M ai nt ai n and supports your ongoing quality
an organization prepare for survey. Tools & Intracycle improvement efforts.
• Document checklists, compliance tips, • Organizations in the Sustaining Improvement
and the lab tracer toolkit helps an organization Resources Monitoring Program (those that have received a decision of
maintain compliance. Preliminary Denial of Accreditation PDA02) are
required to participate, at the 12th month after their
survey, in a dedicated consultative call (TouchPoint)
with the Standards Interpretation Group.
Figure 1. The Joint Commission’s Laboratory Accreditation Program is designed to help laboratories
achieve, maintain, and demonstrate consistent excellence in the services they provide to patients. The
program has several key components designed to work collectively to better power your overall performance
improvement efforts.
The Joint Commission’s Laboratory

Accreditation Program
The Joint Commission’s Laboratory Accreditation Program uses a patient-centered
quality framework and collaborative approach to help organizations proactively identify
and address vulnerabilities to safeguard patients.
Addressing Complex Issues in Laboratories

Accredited by The Joint Commission
There are many factors that affect the outcomes patients receiving laboratory services
experience. For example, having a sufficient number of staff members to support testing
services will help prevent adverse outcomes such as inaccurate or delayed testing results.
Likewise, having educated, competent, and properly trained staff positively impacts the
organization’s ability to assess, plan, and deliver safe, high-quality test results in a timely
manner.
Research shows that some of the greatest challenges for laboratories are addressing
diagnostic errors, obtaining optimum patient specimens that are labeled correctly, order
entry mistakes, equipment performance, clerical errors, and failures in the reporting of
test results and other required documentation.
The Laboratory Accreditation Program helps providers achieve, maintain, and demon-
strate consistent excellence in the services they provide. The standards specifically listed
in Table 1 can help laboratories develop strategies to address some of the most
challenging and complex issues described previously.
Note: Table 1 does not address all of the accreditation-related issues facing leaders in
laboratories. Challenges may differ depending on the setting and population the
organization serves, as well as the services provided.
Table 1. Standards That Address Complex Issues in

Laboratories
Patient Specimens Test Orders Equipment

DC.01.01.01 DC.01.02.01 EC.02.04.01
DC.01.03.01 DC.01.02.03 EC.02.04.03
HR.01.06.01 HR.01.06.01
NPSG.01.01.01 LD.04.01.11
QSA.04.07.01 QSA.02.01.01
QSA.05.07.01 QSA.02.02.01
QSA.13.03.01 QSA.02.03.01
QSA.02.04.01
QSA.02.06.01
QSA.02.08.01
QSA.02.10.01
QSA.05.04.03
Personnel Clerical Errors Result Reporting
HR.01.01.01 HR.01.06.01 DC.02.01.05
HR.01.02.05 QSA.02.11.01 DC.02.01.07
HR.01.04.01 QSA.02.12.01 DC.02.02.01
HR.01.05.03 DC.02.03.01
HR.01.06.01 DC.02.04.01
HR.01.07.01 DC.03.01.01
WT.03.01.01 NPSG.02.03.01
WT.05.01.01
Promoting a Patient-Centered
Proficiency Testing Approach Safety Culture
QSA.01.01.01 HR.01.05.03 APR.09.02.01
QSA.01.02.01 HR.01.07.01 HR.01.04.01
QSA.01.03.01 LD.04.03.01 LD.03.01.01
QSA.01.04.01 LD.03.02.01
QSA.01.05.01 LD.03.03.01
LD.03.04.01
LD.03.05.01
LD.03.06.01
LD.03.09.01
Following the direction provided in these standards and focusing on the patient will
allow staff to begin to explore ways to improve care, treatment, or services to help
patients in attaining the most favorable outcomes possible. A self-assessment using the
Intracycle Monitoring (ICM) process (discussed in more detail in “The Accreditation
Process” [ACC] chapter) and the information on your Joint Commission Connect
extranet site can help you focus on organization-specific problem areas. An understand-
ing of the complex issues addressed by these standards will help you assess just how
ready for accreditation your organization is and will allow you to continually assess your
organization’s readiness going forward.
II. About the Comprehensive Accreditation

Manual for Laboratory and Point-of-Care
Testing
The CAMLAB contains Joint Commission standards (also known as requirements),
elements of performance (EPs), National Patient Safety Goals® (NPSGs), and other
requirements applicable to the care, treatment, or services a laboratory provides (see the
“Identifying Applicable Standards” section in this chapter). The CAMLAB includes all
the information a laboratory needs to achieve and maintain continuous compliance with
The Joint Commission’s accreditation standards. The manual also will help laboratories
engage in continuous performance improvement and will guide staff in developing
processes to provide the highest quality of safe care, treatment, and services.
Upon initial application for accreditation and receipt of a deposit toward accreditation
fees, a laboratory receives access to E-dition (which contains accreditation and
certification standards) and to the Joint Commission Connect extranet (which contains
various accreditation tools and resources to help prepare for and maintain accreditation).
This secure extranet site also serves as the primary avenue for communication between
an organization and The Joint Commission.
The Joint Commission may revise accreditation or certification standards periodically
throughout the year. These changes are published online (in E-dition), in the
accreditation manual, and in Joint Commission Perspectives®, the official Joint
Commission newsletter that publishes revised or updated standards, EPs, scoring,
standards clarifications and interpretations, and other useful information as the year
progresses. Because your organization is responsible for meeting all applicable
standards published in Perspectives, it is strongly recommended that staff are ensured
access to your monthly copy of Perspectives to aid in your compliance efforts (see “Keep
Current with Standards Changes via Perspectives” section). Perspectives is available on
your Joint Commission Connect extranet site under the “Resources” tab and also may be
purchased at www.jcrinc.com/the-joint-commission-perspectives/.
The Joint Commission’s website offers e-Alerts for new content or updates. Sign up for
or update e-Alerts subscriptions at https://www.jointcommission.org/e-alerts/.
Changes to the standards, which occur for a variety of reasons, are developed with input
from accredited organizations, health care professionals, providers, internal and external
subject matter experts, consumers, government agencies, and/or employer groups and
are informed by the scientific literature. New standards are added only if they relate to
patient safety or quality of care and/or have a positive impact on health outcomes, can
be accurately and readily measured, and relate to important issues that clearly support
high-quality care, treatment, or services. Standards may also be revised in response to law
and regulation changes.
Although The Joint Commission may announce revisions to accreditation standards
throughout the year, those changes are made to E-dition generally only twice a year: in
the spring (with changes applicable July 1) and in the fall (with changes applicable
January 1 of the following year). Accredited organizations receive one complimentary
subscription to E-dition as long as they maintain accreditation. The print version of the
CAMLAB is published once a year in the fall; it is available for purchase at https://
www.jcrinc.com/store/publications/manuals/. The “What’s New” table, provided with
each print manual and accessible from the blue navigation bar across the top of E-dition,
offers a summary of the changes made since the CAMLAB was last published or posted.
How Is This Manual Organized?

This manual is organized into the following two sections for your convenience:
■ Section 1: Accreditation Requirements (marked with gold tabs in the print version
and under the “Accreditation Requirements” drop-down list in E-dition). These
chapters include standards that are scored, and they appear in alphabetical order.
■ Section 2: Accreditation Process Information (marked with blue tabs in the print
version and under the “Accreditation Process Info” drop-down list in E-dition).
This section includes information about the accreditation process, policies,
procedures, and other related information.
Following is more detail about each section. See Table 2 for a list of acronyms used in
this manual.
Table 2. Acronyms Used in This Manual
Acronym Meaning
ACC “The Accreditation Process” chapter
AFS Accreditation with Follow-up Survey
APR “Accreditation Participation Requirements” chapter
Comprehensive Accreditation Manual for Laboratory and Point-of-

CAMLAB Care Testing
CLIA Clinical Laboratory Improvement Amendments
CMS US Centers for Medicare & Medicaid Services
DA Denial of Accreditation
DC “Document and Process Control” chapter
E-App electronic application for accreditation
EC “Environment of Care” chapter
EM “Emergency Management” chapter
EP element of performance
ESC Evidence of Standards Compliance
FOC Focused Survey
FSA Focused Standards Assessment
HAI health care–associated infection
HIPAA Health Insurance Portability and Accountability Act of 1996
HR “Human Resources” chapter
IC “Infection Prevention and Control” chapter
ICM Intracycle Monitoring
ILSM interim life safety measures
IM “Information Management” chapter
“Introduction: How Joint Commission Accreditation Can Help on the

INTRO Road to High Reliability” chapter
continued on next page
Table 2. (continued)
Individualized Quality Control Plan (a voluntary quality control option

IQCP for clinical laboratories)
LD “Leadership” chapter
LTA Limited, Temporary Accreditation
NPSG National Patient Safety Goals® (also a chapter in this manual)
OQPS Office of Quality and Patient Safety
OSHA Occupational Safety and Health Administration
PDA Preliminary Denial of Accreditation
PFI Plan for Improvement
PI “Performance Improvement” chapter
POA Plan of Action
PS “Patient Safety Systems” chapter
QR “The Joint Commission Quality Report” chapter
QSA “Quality System Assessment for Nonwaived Testing” chapter
RCA root cause analysis
RFI Requirement for Improvement
RWD “Required Written Documentation” chapter
SAFER® Survey Analysis for Evaluating Risk®
SAG “Standards Applicability Grid” chapter
SE “Sentinel Event Policy” chapter
SIG Standards Interpretation Group
SOC Statement of Conditions™
TS “Transplant Safety” chapter
WT “Waived Testing” chapter
Accreditation Requirements
The first section of this manual contains the accreditation standards for the Laboratory
Accreditation Program, which consists of Joint Commission standards, EPs, and other
requirements applicable to all organizations accredited in the Laboratory Accreditation
Program.
This manual contains the following standards chapters:
“Accreditation Participation Requirements” (APR): Consists of specific requirements
for participation in the accreditation process and for maintaining an accreditation
award.
“Document and Process Control” (DC): Contains a comprehensive set of requirements
for the pre- and post-analytical phases of testing and describes the procedures for
specimen collection, ordering of laboratory tests, and step-by-step description of the
performance of each test.
“Environment of Care” (EC): Describes how to maintain a safe, functional, and
effective environment for patients, staff, and other individuals in the organization.
Includes requirements that address fire safety.
“Emergency Management” (EM): Ensures that the organization has a disaster plan in
place.
“Human Resources” (HR): Outlines requirements for personnel roles required for
nonwaived testing as listed in the Clinical Laboratory Improvement Amendments of
1988 and processes for staff orientation, training, competency, and management.
“Infection Prevention and Control” (IC): Helps organizations identify and reduce the
risk of acquiring and transmitting infections.
“Information Management” (IM): Directs organizations to obtain, manage, and use
information to provide, coordinate, and integrate care, treatment, and services.
“Leadership” (LD): Reviews structure and relationships of leadership and the
maintenance of a culture of safety, quality, and operational performance.
“National Patient Safety Goals” (NPSG): Includes specific actions that organizations are
expected to take to prevent medical errors, such as harm associated with inaccurate
patient identification, delayed communication on critical test results, and health care–
associated infections.
“Performance Improvement” (PI): Focuses on using data to monitor performance,

compiling and analyzing data to identify improvement opportunities, and taking action
on improvement priorities.
“Quality System Assessment for Nonwaived Testing” (QSA): Focuses on specific
analytical requirements to produce quality nonwaived test results in various laboratory
specialties. Also includes regulatory requirements on proficiency testing and quality
control requirements.
“Transplant Safety” (TS): Focuses on the development and implementation of policies
and procedures for safely acquiring, receiving, storing, and issuing tissues.
“Waived Testing” (WT): Covers policies, identifying staff responsible for performing
and supervising waived testing, competency requirements, quality control, and
recordkeeping.
Accreditation Process Information

In addition to the standards chapters, the manual and E-dition include information
about the accreditation process, policies, procedures, and other related information. The
“Accreditation Process Information” part of the manual comprises the following
chapters:
“Patient Safety Systems” (PS): Informs and educates leaders about the importance and
structure of an integrated patient safety system. This chapter is designed to clarify the
relationship between Joint Commission accreditation and patient safety. It does not
contain new standards or requirements. Rather, the chapter describes how existing
requirements can be applied to continually improve patient safety. It also provides
approaches and methods that may be adapted to remove risk of patient harm.
“The Accreditation Process” (ACC): Provides information about The Joint Com-
mission’s accreditation process, including the application process, types of surveys,
Tailored Survey Policy, and Intracycle Monitoring (ICM). The chapter also describes all
components of the accreditation process, including the survey agenda, tracer method-
ology, The Joint Commission’s Information Accuracy and Truthfulness Policy, and the
Public Information Policy. Details of the scoring and decision process, including the
Accreditation Decision Rules, Evidence of Standards Compliance, and the review and
appeal process, are also explained.
“Standards Applicability Grid” (SAG): Provides a list of the standards that are
applicable to laboratories. The user-friendly format allows you to quickly identify the
services, as you identified them in your E-App, and the related standards that apply to
your laboratory.
“Sentinel Event Policy” (SE): Contains information on The Joint Commission’s
Sentinel Event Policy, including the definition of a sentinel event, the goals of the
policy, the adverse events that constitute sentinel events, sentinel event–related
standards, and the various activities that surround the policy.
“The Joint Commission Quality Report” (QR): Provides an overview of publicly
viewable accreditation information provided in the form of Quality Reports. It describes
what Quality Reports are, how and when they are developed, how organizations can
respond to them, and how the public and organizations can access and use them. It also
includes information about The Joint Commission’s Quality Check® website, guide-
lines for submitting commentary, and marketing and communications guidelines for
using Quality Reports.
“Required Written Documentation” (RWD): Lists the standards that require written
documentation beyond that required in the medical record—that is, all the EPs marked
with a icon throughout the standards chapters. This chapter can be used as a
checklist by accredited organizations to maintain continuous compliance with documen-
tation requirements or by organizations seeking accreditation to verify compliance with
those requirements.
“Appendix A: Retention Times for Records, Reports, and Specimens” (AXA): Lists
the minimum required retention times for various records, reports, and specimens. In
instances where state or local regulations require longer retention periods, the laboratory
must conform to those.
“Appendix B: Laboratory Developed Tests” (AXB): Lists the standards and EPs that, in
addition to those found in the Molecular Biology column of the SAG chapter, may be
applicable to laboratories performing Laboratory Developed Tests (LDTs) in a
particular specialty or subspecialty.
“Appendix C: Individualized Quality Control Plan–Eligible Requirements” (AXC):
Contains the general and specialty/subspecialty quality control requirements eligible for
the Individualized Quality Control Plan (IQCP) approach. Laboratories that choose to
implement IQCP are still required to follow all other non–IQCP eligible Joint
Commission quality control requirements.
“Appendix D: Duplicate Laboratory and Hospital/Critical Access Hospital Require-

ments” (AXD): Lists selected duplicate requirements organizations may choose not to be
surveyed against when laboratories are included in Joint Commission -accredited
hospitals or critical access hospitals and are seeking accreditation by the Joint
Commission Laboratory Accreditation Program.
“Glossary” (GL): Provides definitions of many terms used throughout the manual.
“Index” (IX): Appears at the end of the print manual.
Identifying Applicable Standards

The print version of the CAMLAB includes all Joint Commission standards that apply
to all organizations accredited under the Laboratory Accreditation Program. Not all
standards in the print manual apply to the specific care, treatment, or services that your
individual organization provides; your settings; or the populations you serve. You are
not expected to comply with standards that do not apply to the services, settings, or
populations of your organization. If you are unsure about the standards in the print
manual that apply to your laboratory, please review the SAG chapter.
In contrast, the E-dition on your Joint Commission Connect extranet site displays only
the standards applicable to your organization as identified in your E-App. The E-App,
available on your Joint Commission Connect extranet site, gives your organization the
ability to select the specific laboratory settings that describe your organization and the
specific services you provide. This selection, in turn, drives the standards applied to your
organization by surveyors during the survey process and displayed in your organization-
specific E-dition. To view your organization’s services in E-dition, click “Service Profile”
on the top navigation bar. Check with your Joint Commission account executive if you
have questions or to help you ensure your E-App is complete and accurate.
Some organizations provide care, treatment, or services that are covered under more than
one accreditation program and manual (for example, a laboratory with an ambulatory
care center/clinic or home care setting will be required to maintain compliance with
certain standards in the ambulatory or home care accreditation manuals as well as the
CAMLAB). The Joint Commission will work with your organization to determine
whether standards from this and/or other accreditation manuals are applicable.
Standards for the following 10 Joint Commission accreditation programs are available
on E-dition (the names of the corresponding print or PDF manuals, if available, are
indicated in parentheses):
1. Ambulatory Care (Comprehensive Accreditation Manual for Ambulatory Care):
Surgery centers, community health centers, group practices, imaging centers, sleep
labs, rehabilitation centers, student health centers, urgent care clinics, and other
ambulatory providers
2. Assisted Living Communities (Comprehensive Accreditation Manual for Assisted
Living Communities): Organizations that provide residency and services to residents,
which may include assistance with activities of daily living, medication adminis-
tration, and dementia care
3. Behavioral Health Care and Human Services (Comprehensive Accreditation Manual
for Behavioral Health Care and Human Services): Organizations that provide mental
health services, substance use disorder treatment services, foster care services,
programs or services for children and youth, child welfare, services for individuals
with eating disorders, services for individuals with intellectual/developmental
disabilities of various ages and in various organized service or program settings, case
management services, peer-based recovery services, prevention and wellness pro-
motion services, corrections-based services, opioid treatment programs, and psychi-
atric rehabilitation/community support services
4. Critical Access Hospital (Comprehensive Accreditation Manual for Critical Access
Hospitals): A hospital that offers limited services and is located more than 35 miles
from a hospital or another critical access hospital, or is certified by the state as being a
necessary provider of health care services to residents in the area. It maintains no
more than 25 beds that could be used for inpatient/swing bed care. A critical access
hospital provides acute inpatient care for a period that does not exceed, on an annual
average basis, 96 hours per patient. A critical access hospital can also have a
psychiatric and/or rehabilitation distinct part unit; each unit can have up to 10 beds.
5. Home Care (Comprehensive Accreditation Manual for Home Care): Organizations
that provide home health services, personal care and support services, pharmacy
services including infusion services and/or mail order and specialty pharmacies, long-
term care pharmacies and freestanding infusion centers, durable medical equipment
services, and hospice services
6. Hospital (Comprehensive Accreditation Manual for Hospitals): General, acute
psychiatric, pediatric, medical/surgical specialty, long-term acute care, and rehabili-
tation hospitals
7. Laboratory Services (Comprehensive Accreditation Manual for Laboratory and Point-

of-Care Testing): Clinical laboratories, point-of-care testing, assisted reproductive
technology labs, and reference labs performing nonwaived testing
8. Nursing Care Centers (Comprehensive Accreditation Manual for Nursing Care
Centers): Organizations that provide specialized services to patients or residents,
which may include rehabilitative care, dementia-specific memory care, and long-term
nursing care
9. Office-Based Surgery Practices: A surgeon-owned or -operated organization (for
example, a professional services corporation, private physician office, or small group
practice) that provides invasive procedures and administers local anesthesia, minimal
sedation, conscious sedation, or general anesthesia that renders three or fewer
patients incapable of self-preservation at any time, and is classified as a business
occupancy
10. Telehealth (Comprehensive Accreditation Manual for Telehealth): Organizations that
provide care, treatment, and services via telehealth, which may include freestanding
organizations that only provide care, treatment, and services via telehealth, as well as
organizations that provide care, treatment, and services via telehealth to another
organization’s patients
Contact your account executive with questions about eligibility or the services or
settings that will be included in your survey.
Understanding the Organization of the

Standards Chapters
Each standards chapter in the “Accreditation Requirements” section is organized as
follows (see Figure 2):
■ Overview: The overview is located at the beginning of each chapter. The overview
explains the chapter’s purpose and the principles on which the standards were built.
■ Chapter outline: This part shows how the chapter is laid out and provides a frame of
reference for the numbering of standards.
■ Introduction: Some standards (or cluster of standards) have an introduction at the
beginning, which provides information about the standard’s origin and any issues
that surround it.
■ Standards: Standards (also known as requirements) are statements that define the
performance expectations and/or structures or processes that must be in place for
organizations to provide safe, high-quality care, treatment, and services.
■ Rationale: A rationale explains the purpose of a standard by providing additional

background, justification, or other information, but it is not scored. In many cases,
the rationale for a standard is self-evident; therefore, not every standard has a
written rationale.
■ References: This part of a chapter is placed in parentheses following a standard to
help identify related standards, whether they are located in the same chapter or a
different chapter. These references should help the user to quickly find related
standards concerning a particular topic.
■ Elements of performance (EPs): EPs are statements that detail the specific
performance expectations and/or structures or processes that must be in place for
an organization to provide high-quality care, treatment, or services. EPs are scored
and determine an organization’s overall compliance with a standard. The EPs are
numbered sequentially under each standard: EP 1, EP 2, EP 3, and so on. Some EPs
in standards common across accreditation programs may not apply specifically to
laboratories and are omitted from this accreditation manual. Consequently, gaps
may exist in the sequence. For example, if a standard lists EP 1, EP 2, and EP 5, this
indicates that EP 3 and EP 4 do not apply to the Laboratory Accreditation Program
and, therefore, your organization does not have to comply with them.
■ Notes: Notes are used to provide organizations and surveyors with additional or
clarifying information about a specific EP.
■ Worksheets: The following worksheets are accessible on the chapter navigation bar
in E-dition and included at the end of each standards chapter in the print manual:
❏ Prompts to Assess Your Compliance: These worksheets contain questions to
prompt discussion in your organization about compliance with the standards in
a particular chapter. In some instances, there are tips with helpful standards
compliance strategies.
❏ Written Documentation Checklist: These checklists contain the EPs that require
written documentation (shown with a icon in the chapter) that a surveyor
may ask to see during a survey to assess compliance.
❏ Action Planning Tool: These forms can be used to track EPs that are out of
compliance and to document the steps your organization will take to bring
them into compliance.
❏ Chapter Notes: These blank sheets in your print manual can be used to record
notes and information, such as the location of documents or medical record
numbers used to assess compliance, so you have them at the ready for reference.
Figure 2. Components of a standards chapter in the print manual. The components are further
described in the “Understanding the Icons Used in the Manual” section.
Understanding the Icons Used in the Manual

You will notice features in the manual that will help you navigate the standards. Icons
used throughout the accreditation requirements chapters provide clarity and ease of use.
The following icons can be found in this manual:
■ The documentation icon indicates when written documentation is required to

demonstrate compliance with an EP. In addition, the word written usually appears
in the text if an EP requires written documentation, which may be in either a paper
or an electronic format. Because The Joint Commission’s focus is on performance
and implementation rather than documentation, the EPs require documentation
only when it is essential. A documentation icon is used to identify data collection
and documentation requirements that are beyond information required to be in the
clinical record. For example, an EP that requires a written procedure will include a
, but the icon is not applied to an EP that contains the required list of
components of the clinical record. Other examples in which the documentation
icon is used are for EPs that require a policy, a written plan, bylaws, a license,
evidence of testing, data, performance improvement reports, medication labels,
safety data sheets, or meeting minutes. Each EP that requires any of these types of
documentation is listed in the Written Documentation Checklist at the end of each
standards chapter in this manual.
■ The risk icon identifies specific risks by accreditation program (not program
segment). Risk is assessed by a system’s proximity to the patient, probability of
harm, severity of harm, and number of patients at risk. Risk categories identified by
The Joint Commission are related to National Patient Safety Goals, accreditation
program–specific risk areas, and RFIs identified during current accreditation cycle
survey events. The print manual will show a single icon at the EP level for the
National Patient Safety Goals and accreditation program–specific risk areas that are
required to be addressed during the ICM process through the FSA. The third risk
category—related to an organization’s own RFIs—will appear only in the ICM
Profile on the organization’s Joint Commission Connect extranet site.
III. Steps to Achieving and Maintaining

Compliance
Communicating critical information to staff and maintaining continuous compliance
with Joint Commission standards are key to ensuring that safe, high-quality care is
provided to patients—yet these charges present a real challenge for many organizations.
Following are some helpful suggestions for successfully achieving continuous com-
pliance with accreditation standards outlined in this accreditation manual.
Become Familiar with the Standards

Although there may be one or more staff members with sole accreditation responsi-
bilities who should read all parts of each chapter in this manual, it is more likely that
several individuals or teams will need to know and understand one or more sections or
chapters. Therefore, it is important for organizations to make the information readily
available to such staff. Grant guest access to your Joint Commission Connect extranet site
to allow staff access to E-dition and educate key staff on how to access E-dition
standards under the “Resources” section. Or, make the CAMLAB readily available to
staff by keeping a copy or multiple copies of the print manual in an easily accessible
location, such as a resource center or other central location. Let staff and others know
that the manual is available and how they can access it.
The “Requesting Permission to Share Content from the Manual” section provides
contact information and guidelines for purchasing copies of the CAMLAB, requesting
permission to make copies of your print manual, or purchasing a site license for E-dition
to make accreditation standards more widely available to staff.
Use the Standards to Improve Quality

Laboratories face a number of complex issues and challenges when performing testing.
Table 1 lists some of the most common and challenging issues in laboratories as well as
the standards in the CAMLAB that help organizations address these topics. Laboratories
should not view these standards—or any standards in the manual—as rules that must be
followed just for Joint Commission survey purposes but should instead incorporate
tasks and processes that help integrate these concepts into your daily operations because
they directly affect the safety of patients and the quality of care, treatment, and services
you provide.
Assess Compliance with the Standards

Determine whether your organization is in compliance and how consistently you are
performing. This can be accomplished in a number of ways, including the following:
■ Use the ICM profile and FSA tool on your Joint Commission Connect extranet site
to prepare for your initial survey or maintain compliance between surveys (see
Figure 3). Contact your account executive for support.
■ Create or use a checklist to evaluate compliance for each standard, or turn each
standard into a question. For example: Is our interdisciplinary team consulted when
necessary to determine whether a prospective patient is eligible for admission? Does
my organization assess the patient’s risk for falls?
■ Monitor The Joint Commission’s website for free tools and resources provided,
such as workplace violence prevention resources (https://www.jointcommission.
org/resources/patient-safety-topics/workplace-violence-prevention/).
■ Use the manual to perform mock tracers or a mock survey. Plot your compliance on
a Survey Analysis for Evaluating Risk® (SAFER®) Matrix. (For more details on
plotting your compliance, see “The Scoring Process” section in “The Accreditation
Process” [ACC] chapter or the SAFER Matrix scoring process fact sheet at https://
www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-
safer-matrix-scoring-process/.)
■ Use the worksheets at the end of each standards chapter to track compliance with
the standards in the chapter and to trace progress for coming into compliance.
■ Turn accreditation standards into PowerPoint presentations, handouts, study aids,
posters, or other staff education materials. They also can be rewritten as quizzes,
tests, or worksheets to determine staff understanding.
■ Compile information on your performance improvement activity for discussion
during your survey.
■ Form a team to develop creative ways to assess, achieve, and maintain standards
compliance, such as the following:
❏ Question of the week or month
❏ Standards-related posters
❏ Column in a weekly all-staff newsletter or electronic bulletin board
■ Speak to other accredited program coordinators. To find other accredited programs,
go to https://www.qualitycheck.org and search by organization, service/setting,
state, city, or zip code.
■ Conduct a gap analysis for the activities required by the standards and evaluate your
organization against each standard. Identify whether the standard is being (or has
been) met or not met.
INTRO – 22
KEY MILESTONES IN THE ACCREDITATION PROCESS
Joint Commission Activities

Full survey
is conducted
Full survey is
Within 30 days of submission, SIG (between 21 to 24
conducted
conducts TouchPoint conference FSA survey is months)
using tracer
call with organizations involved scheduled
methodology Biennial
in the Sustaining Improvement to occur in 2
Program (meeting the decision to 6 months accreditation
Summary of
rule of PDA02) and reviews and following cycle begins
findings left
approves POA from FSA (as submission if again
for organization
necessary) requested
patients for safe, high-quality care.

Accreditation FSA
decision rendered activated for
Survey is submission Resurvey is
Quality Report™ (due by
scheduled scheduled
posted on Quality month 9)
Check®
Stimulate Improvement
-6 -3 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Application Year One Year Two
Organization Organization
Organization completes
completes and submits ESC Organization
and submits ICM profile
submits E-App updates and
(including selected FSA
Figure 3. Events in a full two-year laboratory accreditation cycle.

and deposit, if submits E-App
option), develops POA
required for resurvey
for standards identified
E-dition and ICM as noncompliant, and
FSA tool made identifies their date of

available compliance
Accredited Organization Activities
* Activities The Joint Commission completes appear above the time line; activities conducted by the organization appear below the time line.
FSA, Focused Standards Assessment; SIG, Standards Interpretation Group; POA, Plan of Action; E-App, electronic application; ICM, Intracycle Monitoring;
ESC, Evidence of Standards Compliance.
organization complies with Joint Commission standards and meets the needs of your
After a standards assessment has been completed, there likely will be follow-up action
needed to bring your organization into compliance. Following are tips to make sure your
CAMLAB Update 1, July 2024

■ Teach leaders and management staff how to access the standards on E-dition so that
they can reference them frequently for help in maintaining compliance.
■ Create an online Joint Commission electronic bulletin board on your organization’s
internal website to give staff updates about compliance, allow them to check
standards, and post questions about the accreditation process. Be sure to include
any links to outside sources that can help staff understand why a standard is
important to safe care.
■ Use an internal online discussion board to help staff recognize existing compliance
processes and to integrate new processes into everyday work.
■ Use the ACC chapter to access accreditation policies and information about what
happens before, during, after, and between surveys.
■ Take note of any standards you need assistance with, and make an action plan to
achieve compliance. You can use the Action Planning Worksheets at the back of
each standards chapter to track your progress. (See the “Assess Compliance with the
Standards” section for more information.) Take advantage of the ICM FSA tool (or
another preferred resource) that allows the organization to score each standard and
EP, develop an action plan, assign a responsible party, set goal dates, run reports,
and monitor progress toward achieving full compliance with all the standards.
■ Obtain answers to standards compliance questions online using the Standards
Interpretation frequently asked questions (FAQs) at https://www.jointcommission.
org/standards/standard-faqs/.
❏ Save the link on your intranet or add it to your favorites list and encourage staff
to regularly check the FAQs for laboratories or search by keyword.
❏ When an FAQ provides helpful information that clarifies an intended rationale
or requirement, consider including it in an online discussion board or
electronic accreditation portal accessible to staff or print it out and insert a
copy of the FAQ in your print manual or an accreditation binder.
❏ If you are unable to find the answer you need, accredited organizations may
submit their own question using the online submission process on the FAQ
page via your Joint Commission Connect extranet site (see the “Standards
Questions” section for more information).
■ Use resources and tools provided to all organizations on your Joint Commission
Connect extranet site. In addition to E-dition, tools available on the site include the
following:
❏ Heads-Up Report: A program-specific report that identifies important topics

and themes that Joint Commission surveyors are reporting and citing during
surveys. This downloadable report is posted at least quarterly in the “Resources
and Tools” section on an accredited organization’s secure Joint Commission
Connect extranet site.
❏ Survey Planning Tools: Helpful information including a survey activity list,
required written documentation list, and survey preparation notes to help you
plan for the logistics and operational needs of a survey.
❏ Survey Activity Guide: A resource to help you prepare for survey, including an
abstract of each survey activity with logistical needs, session objectives, an
overview of the session, and suggested participants.
❏ SAFER Matrix Information: A collection of resources to provide organizations
with information related to the Survey Analysis for Evaluating Risk (SAFER)
process.
❏ ICM Profile: To assist with continuous compliance efforts, this profile includes
all the standards and EPs but specifically identifies high-risk areas and utilizes
the FSA tool to identify related standards marked with a risk icon .
❏ Standards Interpretation: A landing page that allows organizations to submit
questions and view FAQs related to the interpretation of standards.
Keep Current with Standards Changes via

Perspectives
Reading Perspectives each month provides critical information about changes to
standards and policies that are made throughout the year. Doing so allows you to learn
about initiatives underway to support your efforts to achieve and sustain performance
excellence. Note the changes in your manual or electronically because your organization
is responsible for complying with all applicable Joint Commission standards (new and
revised), including any changes published in Perspectives.
Current and recent editions of Perspectives are available on your Joint Commission
Connect extranet site, made available to organizations that are accredited or have applied
for accreditation. Staff who don’t have access to their organization’s secure extranet site
can “Request Guest Access” on The Joint Commission’s website at https://www.
jointcommission.org/login/ to view Perspectives. Before signing up, staff must know the
organization’s health care organization (HCO) identification (ID) number (which can
be found on Quality Check). Staff signing up will receive automatic access if using a
work e-mail address in a location with a valid domain that matches the HCO ID domain
on file. For staff using a computer without the HCO’s domain, a message will be sent to
the primary accreditation contact at the organization for approval.
In addition to reading Perspectives, there are several other ways to keep track of standards
changes:
■ Check The Joint Commission’s website (https://www.jointcommission.org
/accreditation-and-certification/health-care-settings/laboratory-services/) regularly
for any revisions to laboratory standards published in Perspectives.
■ Sign up for news and alerts, including standards changes, by clicking on “Subscribe
to E-Alerts” on The Joint Commission’s home page at https://www.jointcommis-
sion.org.
■ Use the “What’s New” feature (see Figure 4, below) found on the blue navigation
bar running along the top of E-dition or at the front of the print manual to become
familiar with changes that occurred since the last E-dition or print release. You can
also sort by new and changed EPs as of the selected effective date by clicking on the
“Filters” feature on the blue navigation bar.
Figure 4. “What’s New” feature on E-dition.
■ Check e-Alerts subscriptions on The Joint Commission’s website for new content
or updates. Sign up for or update e-Alerts subscriptions at https://www.joint
commission.org/e-alerts/.
IV. Get Extra Help

All laboratories—regardless of size and scope of services—are entitled to ask for and
receive additional support during the accreditation cycle. The following items provide a
broad list of accreditation contacts at The Joint Commission and information and
guidelines for maximizing your accreditation resources from Joint Commission
Resources.
Getting Started with Accreditation

Organizations not yet accredited can contact Business Development at
[email protected] for information about the following:
■ Benefits of Joint Commission accreditation and certification offerings
■ Obtaining accreditation and certification
■ Initial application
■ Time-limited complimentary access (on E-dition) to laboratory requirements
Account Executive
Accredited organizations can call their assigned account executive at 630-792-3007 for
information or with questions about the following:
■ Scheduling of surveys
■ Survey agenda or survey process
■ Status of a Final Accreditation Report
■ Content of a Final Accreditation Report
■ ESC submission process
■ Other survey activities
■ Accessing and completing the Focused Standards Assessment
The name and contact information for your assigned account executive can be found on
the home page of your Joint Commission Connect extranet site.
Contacting The Joint Commission

The Joint Commission’s main telephone number is 630-792-5000. The Joint Com-
mission’s business hours are 8:30 A.M. to 5:00 P.M. central time, Monday through Friday.
Additional contact information can be found on The Joint Commission’s website at
https://www.jointcommission.org. Access your Joint Commission Connect extranet site
at https://customer.jointcommission.org/ (available to accredited organizations or those
that have applied for accreditation) for organization-specific and general accreditation
information and free resources.
Standards Questions
Should you have a question about a standard, check the frequently asked questions
(FAQ) repository online at https://www.jointcommission.org/standards/standard-faqs/.
If you don’t see your question addressed, please note that applicant and accredited
organizations can submit a question via http://web.jointcommission.org/sigsubmission/
sigquestionform.aspx using the online submission process described on the FAQ page or
via your Joint Commission Connect extranet site (under “Resources and Tools”).
Requesting Permission to Share Content from

the Manual
Organizations accredited by The Joint Commission are allowed to make up to 10 copies
of the print CAMLAB free of charge by e-mailing a request to [email protected].
Call the Joint Commission Resources (JCR) Customer Service telephone number at
877-223-6866 (between 8:00 A.M. and 8:00 P.M. eastern time, Monday through Friday) or
visit the JCR Store at https://jcrinc.com to purchase helpful compliance resources,
including print copies of the manual, books and e-books, software programs, monthly
newsletters, custom education, or consulting.

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Introduction: How Joint

Commission Accreditation Can

I. Introduction to Joint Commission

■ Enhances staff education: The accreditation process is designed to be educational.

Achieve, Maintain, and Demonstrate Consistent Excellence

Nationally Recognized Standards On- and Off-Site Evaluations

Tools and Resources Intracycle Monitoring

The Joint Commission’s Laboratory

Addressing Complex Issues in Laboratories

Table 1. Standards That Address Complex Issues in

Patient Specimens Test Orders Equipment

II. About the Comprehensive Accreditation

How Is This Manual Organized?

Table 2. Acronyms Used in This Manual

ACC “The Accreditation Process” chapter

AFS Accreditation with Follow-up Survey

APR “Accreditation Participation Requirements” chapter

Comprehensive Accreditation Manual for Laboratory and Point-of-

CLIA Clinical Laboratory Improvement Amendments

CMS US Centers for Medicare & Medicaid Services

DC “Document and Process Control” chapter

E-App electronic application for accreditation

EC “Environment of Care” chapter

EM “Emergency Management” chapter

ESC Evidence of Standards Compliance

FOC Focused Survey

FSA Focused Standards Assessment

HAI health care–associated infection

HIPAA Health Insurance Portability and Accountability Act of 1996

HR “Human Resources” chapter

IC “Infection Prevention and Control” chapter

ICM Intracycle Monitoring

ILSM interim life safety measures

IM “Information Management” chapter

“Introduction: How Joint Commission Accreditation Can Help on the

continued on next page

Individualized Quality Control Plan (a voluntary quality control option

LTA Limited, Temporary Accreditation

NPSG National Patient Safety Goals® (also a chapter in this manual)

OQPS Office of Quality and Patient Safety

OSHA Occupational Safety and Health Administration

PDA Preliminary Denial of Accreditation

PFI Plan for Improvement

PI “Performance Improvement” chapter

POA Plan of Action

PS “Patient Safety Systems” chapter

QR “The Joint Commission Quality Report” chapter

QSA “Quality System Assessment for Nonwaived Testing” chapter

RCA root cause analysis

RFI Requirement for Improvement

RWD “Required Written Documentation” chapter

SAFER® Survey Analysis for Evaluating Risk®

SAG “Standards Applicability Grid” chapter

SE “Sentinel Event Policy” chapter

SIG Standards Interpretation Group

SOC Statement of Conditions™

TS “Transplant Safety” chapter

WT “Waived Testing” chapter

“Performance Improvement” (PI): Focuses on using data to monitor performance,

Accreditation Process Information