[Histonet] JC requirement for stain QC question

Morken, Timothy Timothy.Morken at ucsf.edu
Wed Oct 19 13:21:32 CDT 2016

Hi all, for those under Joint Commission, can you give your interpretation of this standard having to do with QC of stains?
QSA 13.06.01
The equipment, methods and stains used in producing microscopic slides provides tissue sections that facilitate a diagnosis
Elements of Performance
A 1.  A pathologist qualified in anatomic pathology assesses the staining quality (for example, equipment, methods, stains) of microscopic tissue sections to determine the stains ability to facilitate a diagnosis

C 2.  (D)The Laboratory performs quality controls on histologic stains for intended reactivity. The quality control results are documented. (m)
                Notes: for example, immunohistochemical (IHC) stains have positive and negative controls, and for periodic acid-Schiff 9PAS) stains, documentation
C 3 (D)  Each time of use for patient testing, the laboratory performs quality controls for each type of histologic stain used. The quality control results are documented.

We always read this as the pathologist signs off on a validated stain procedure and the histotechs do the QC of stains (H&E and Special Stains) and document it. The pathologist does not necessarily review the daily QC slides.

The inspector today says that the Pathologist has to review and sign off each daily QC slide.

Does anyone have any experience other than what we normally do?

Tim Morken
Pathology Site Manager, Parnassus
Supervisor, Electron Microscopy/Neuromuscular Special Studies
Department of Pathology
UC San Francisco Medical Center
505 Parnassus Ave, Box 1656
Room S570
San Francisco, CA 94143

(415) 353-1266 (ph)
(415) 514-3403 (fax)
tim.morken at ucsfmedctr.org<mailto:tim.morken at ucsfmedctr.org>

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