POC accreditation

I have a hospital that is inspected under the TJC Lab accreditation.  They only run the epoc.  There is no "lab" in this hospital since we are a hospital in a hospital and our host hospital has the main lab.  Our virtual inspection in March took 8 hours.  They will typically inspect for 3 days depending on your testing volume.  Since our hospital inspection is due this year, we were able to get off lightly on the waived testing but normally they comb through that too.  Lab TJC inspectors are professional inspectors, not that our CAP counterparts aren't thorough.  The TJC Lab Accreditation manual is just as big as the hospital manual with many of the same chapters (Environment of Care, Safety, QSA etc). As your own CLIA number, I think you would be responsible for all the chapters.  I'm not sure if I would recommend switching to Lab TJC.  If you can get a copy of the TJC lab accreditation manual, you can see for yourself what you would be in for.  

I started my POC career in a hospital that had separate Clia licensure for the lab and respiratory running the ABG’s as POC.  The RT dept got inspected by Jhaco shortly after I started, the problem was that the RT dept was using the lab policies and there wasn’t any actual RT policies for what they were doing.  This  included all the supporting stuff  like Reine mentioned: (Environment of Care, Safety, QSA etc) and they got nailed to the wall for not having any of it.  It was bad.  After this, it was decided to merge the two licensures to reduce the cost, workload and duplication of efforts.

Yes, the Jhaco Inspectors inspect for a living and know exactly where to look for issues and they will find them if present.

When splitting out the licensure from the lab and POC there is the benefit that if the POC gets cited the laboratory itself is still OK.  The drawback is you basically have to have all the supporting policies and documentation that another lab would have, you can’t say… oh, well the lab does the QM:   There is more work and more cost in splitting them out.

I wholeheartedly support what Reine and Jeremy have already pointed out.  My hospital also started out with all non-waived (Respiratory Therapy, Cath Lab, and some hospital-based clinics doing PPM + waived and limited non-waived testing) under JC Lab Accreditation because at the time there was no POC coordinator position.  All of these non-lab departments were managed by clinical, non-laboratory managers with no lab input.  All of lab was under CAP.  After a few nightmare inspections by JC, usually over multiple days, the final straw was when JC required training and competency assessment for PPM (which they were warned in 2005 that it was coming in 2007) and when the inspectors arrived in 2007 there was still nothing in place.   Again, another multiple-day inspection for just those few areas, so naturally there was no stone unturned.  Comic note - I remember at one point an inspector was chasing a physician asking them for an example of PPM documentation on a patient and the other physicians were huddled around giggling about it.  Not a fun day.  After the summation with citations all around (and there were plenty because they were all separate CLIA numbers) - the decision was made to have a full-time POC Coordinator.  One of the first things I did is move the non-waived areas away from JC and under CAP along with the rest of the lab, the clinics got rid of their one moderately-complex test and were therefore waived-only and didn't need lab accreditation,  and we haven't looked back since.  Don't do it!