[Histonet] Joint Commission Standards for Pathology

Morken, Timothy Timothy.Morken at ucsf.edu
Thu Jan 7 13:34:35 CST 2021

Amy, they don't have a specific AP and General checklist like CAP has. They have a Standards book that lists all the requirements and you need to go thru and figure out which apply to your area. It is also on line at the TJC site. The thing is that TJC covers the entire hospital, not just the labs, so much of it is for other areas besides the lab. 

They don't do inspections in the way CAP does it. CAP will camp out in your lab for days going over every detail on the checklist. Instead TJC uses "Tracers" and pulls random patient files for random dates of the year and then asks for everything related to those files. So any lab work, reports, QC results, equipment records, personnel records (qualifications, competencies, etc) of anyone who worked on tests for those patients. That is really the part that has to be focused on. In the last 5 inspections I've had from TJC they spent about 30 min in the lab each time. The rest of the time was going over tracer records. In the end it checks the same things, but in a very different way. 

Tim Morken
Supervisor, Electron Microscopy/Neuromuscular Special Studies
Department of Pathology
UC San Francisco Medical Center

-----Original Message-----
From: Amy Self via Histonet <histonet at lists.utsouthwestern.edu> 
Sent: Thursday, January 07, 2021 11:22 AM
To: histonet at lists.utsouthwestern.edu
Subject: [Histonet] Joint Commission Standards for Pathology

Good Afternoon and I hope that everyone had a safe and Happy New Year,

Does Joint Commission offer a checklist like CAP does that is specific to pathology?

Amy Self
Senior Histology Technologist
Tidelands Georgetown Memorial Hospital
606 Black River Road
Georgetown, SC 29440
Office: (843) 520-8711
aself at tidelandshealth.org
Our mission:  We help people live better lives through better health.

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