Volume 2025 | No. 2
SURVEYOR
CLINICAL LABORATORY
■ The laboratory’s policy for tests requiring correlations does not identify criteria of acceptability. ■ Comparison between EXL and the Triage meter failed to meet the laboratory-established criteria on 12/24 (Trop), 6/24 (CKMB), and 12/23 (Trop). Compliance tips for:
■ Water quality records and an interview with the laboratory supervisor revealed that bacterial cultures on the water systems supplying the chemistry analyzers were not performed in 2023. ■ Humidity measurements are taken each day and documented. However, no ranges were referenced on the log to allow staff to determine if readings fall within the acceptable range or require remedial action. Compliance tips for:
Humans vary, and so does equipment. This standard intends to demonstrate consistency through regular comparison testing to isolate and address any outlier results. ■ Develop a list of tests/equipment that require comparison testing. ■ Schedule semi-annual comparisons and audit for completion.
Nerd Newbies (understand the requirement)
The conditions under which materials are stored and tested must be defined and consistently maintained. This applies specifically to temperatures (room and refrigeration), humidity, water quality, and electrical current. Measurements are only as good as the equipment used, so NIST-certified or NIST-traceable tools are required. ■ Audit logs for daily entries. ■ Audit corrective action logs for alignment with reported conditions.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Train staff on acceptable criteria and what to do in the event of an unacceptable comparison.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
■ Train staff on acceptable ranges for essential conditions and what to do in the event of an unacceptable condition.
Nerd Trailblazers (prepare the path for others)
06.08.01 Comparison of test results Frequency of the citation: 15%
Overview of the requirement: If the same test is performed using different methods, different instruments, and/or at multiple locations, the laboratory must compare results at least twice annually and review against written criteria for acceptable variation in test values. Comment on deficiencies: Compliance is assessed through interview and document review. Deficiencies were cited for:
ٝ Failure to perform comparison studies for specific testing methods. ٝ Lack of guidance on action to take in the event of unacceptable variance.
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
Examples of ACHC Surveyor findings: ■ Cell counts using the automated body fluid method were not compared to manual body fluid cell counts. ■ Blood bank tube vs. gel method comparisons were performed at one six month interval, but not at the next expected date. ■ A comparison of the Rapid Point blood gas analyzers was performed at installation (2 years prior to survey), but not since then.
achc.org | (855) 937-2242 | 13
12
Made with FlippingBook interactive PDF creator