TJC initial laboratory accreditation inspection

Aloha Ashlee,

Not familiar with initial inspections, but have done a few reaccreditation surveys.  TJC uses the tracer methodology for inspections.  If you have access to the e-dition standards they have a few checklists/tools that are quite helpful.  They also have document list, that lists most of the documents they will look at during the survey.  Some surveyors may also provide an additional list on top of that.   Hope this helps.

We have a new location that is getting their initial TJC inspection this month. My hospital's Compliance and Accreditation Dept reached out to me wanting a copy of the CLIA license for that location and told me to ensure I have training documents for all staff in that building if TJC were to ask for them. For routine TJC inspections I agree with Shana. TJC uses the tracer method. For us, they will take a patient POC result and trace back to see if QC was performed per policy for that POC test on that specific date. Check any necessary temp logs from that date. Then look up which staff member performed the testing and look at their training and/or competency records for that POC test.  I've also seen TJC inspectors ask direct questions to staff to ensure staff know policy, such as "how/when do you disinfect the POC glucometer?". 

I've worked in different facilities that have used both, including a conversion from CAP to JC. Not to be ominous but when asked this very question: What is the difference between CAP inspections and JC inspections?, I tell them this:  As you are no doubt aware, CAP inspectors are your peers from another facility, most likely of same size and composition, their primary job is essentially the same as yours.  They may be more knowledgeable of the regulations than than you... or much less.  JC inspectors are just that, hired by JC and they just go from one inspection to another.  They are typically far more knowledgeable in the regs and the various systems out there, including their specific issues.  They tend to skip the "fluff" and go straight to the areas that you are more likely to be having issues with compliance.

Just had our initial inspection last week.  They will only go back 4 mos, except for proficiency testing.