SURVEYOR
FROM THE PROGRAM DIRECTOR
CLINICAL LABORATORY
CLIA mandates laboratory surveys on a two-year cycle. This allows for rapid identification and correction of gaps in compliance to ensure quality and consistency in testing for diagnostic purposes. I am pleased to share that, based on survey data collected from June 1, 2024, through May 31, 2025, ACHC-accredited laboratories continue to improve their compliance with our standards. This is true in aggregate as evidenced by the declining number of standards that are noted as deficiencies on at least 15% of the surveys conducted. It is also true at the level of individual standards, where performance has improved from the last survey cycle for this cohort of laboratories.
Trending the data In 2023, 12 standards reached the 15% threshold for inclusion in the Quality Review edition of Surveyor . This year, only seven standards met this criterion. Of these seven, six are repeated from 2023, but in every case, the frequency of citation declined as shown in the chart below.
The most challenging standards tend to be consistent year over year for each of ACHC’s accreditation programs. Often this is because they are broad in scope or include a large number of required elements. This is the third consecutive year that standard 06.02.01 Essential Conditions sits at the top spot. The requirements address water quality, temperature, humidity, and protection from electrical surges for reagents, specimens, and test systems. The good news this year is that it shows a 35% drop from 2023, an indicator that this cohort of laboratories has focused improvement efforts on tracking, documenting, and maintaining consistent environmental conditions. I hope you find this information useful. The ACHC Laboratory Accreditation Program team is here to support problem-solving and to guide you to educational resources. Please don’t hesitate to reach out to us!
Standard 2023 frequency 2025 frequency
01.04.07
17%
15%
02.02.04
32%
15%
02.02.05
27%
24%
ACHC Clinical Laboratory accreditation covers all levels of complexity and all clinical settings from point-of-care waived tests performed in a physician office to high complexity testing in independent or hospital-based laboratories.
03.02.07
19%
17%
06.02.01
37%
24%
06.08.01
25%
15%
Testing Specialties
n Chemistry
n Hematology n Histocompatibility n Immunohematology ABO Group Rh Type Antibody Detection Antibody Identification Compatibility Testing
n Microbiology Bacteriology Mycology Parasitology Virology n Pathology Cytology
n Radiobioassay
New in this year’s report is 05.05.04 Specimen Receipt/Acceptability and Rejection/Processing which was noted as a finding on 19% of the surveys conducted. ACHC Surveyors observed that these labs missed a requirement by failing to document the date and time each specimen was received. This detail can be important for the subsequent acceptance criteria.
Routine Chemistry Urinalysis Endocrinology Toxicology n Clinical Cytogenetics n Diagnostic Immunology General Immunology Syphilis Serology
James Liggins Program Director
Histopathology Oral Pathology
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