Volume 2024 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
The 2020 merger of ACHC and HFAP included significant efforts to provide a smooth transition for existing HFAP customers and a warm welcome to new and transitioning organizations. Because laboratories are surveyed on a two year-cycle, this year’s data analysis represents the second time we are able to compare survey results under the ACHC brand. Trending the Data The newest standard to rise above the 20% deficiency rate was 02.02.05 Personnel competency assessment policies . This standard is closely related to this year’s top deficiency ( 02.02.04 Testing personnel competency and evaluation ). Standard 02.02.04 was cited on 36% of the surveys in this year’s report, climbing from a rate of 28% in 2022. It identifies six elements of competency that must be assessed for every individual on every test they perform. Standard 02.02.05 requires that competency be defined for specific roles. Together, these deficiencies indicate a need for special attention to the details of competency assessment. Labs can come at this from two directions to ensure compliance: an inventory of all tests performed with associated competencies cross referenced to a list of all testing personnel. This includes individuals assigned the role of assessor, i.e., Laboratory Director or Technical Consultant. The other standard that was cited on more than a third of all surveys ( 03.02.07 Quality control for waived tests ) also showed declining performance from 2022 when it was cited on just over a quarter of surveys. Waived testing often occurs outside the laboratory environment, but the laboratory retains responsibility for quality. Surveyors noted that QC was often ignored for this category of commonly administered tests.
The last of the three standards cited more often in this report than two years ago was 04.02.05 , which noted proficiency testing failures. The uptick was less dramatic, from 23% to 27%, but PT failures may correlate with personnel competency. Correcting one may well serve to correct the other. PT testing issues also interrupt laboratory efficiency by limiting testing with specific analytes until improvement is evidenced through corrective action. Standard 06.08.01 , which requires comparison of testing results when the same test is performed using differing methods or equipment, saw improvement, from a 28% rate of deficiency in 2022 to below 20% this year. Finally, 06.02.01 Essential Conditions was noted on 27% of surveys. The standard addresses requirements for water quality, temperature, humidity, and protection from electrical surges for reagents, specimens, and test systems. Tracking, documenting, and maintaining consistent environment conditions remains a consistent challenge. Four standards that just missed the threshold are also detained on the following pages. The laboratory teams hopes you find this information useful. We stand ready to assist with trouble shooting or guiding you to educational resources at any time.
CLINICAL LABORATORY ACCREDITATION
FREQUENT DEFICIENCIES FROM LAB SURVEYS
60%
50%
40%
30%
James Liggins Program Director
20%
10%
0%
DRX1-4A
DRX4-2H
DRX4-2J
DRX4-7A
DRX4-8A
DRX5-1A
DRX7-5B
DRX7-12D
Organization and Administration
Human Resource Management
Provision of Care and Record Management
Risk Management: Infection and Safety Control
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