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TJC Laboratory Accreditation Requirements

TJC identifies the primary responsibility of an organization is to provide for the safety and quality of care, treatment and services. To achieve this, the standards identify five key systems that influence the performance of an organization:

  • using data
  • planning
  • communicating
  • change performance
  • staffing

Standard LD.4.240 indicates 'Leaders establish priorities for performance improvement'. Elements of performance for this standard include:

  • Leaders set priorities for performance improvement activities and patient health outcomes.
  • Leaders give priority to high volume, high risk, or problem prone processes.
  • Leaders reprioritize performance improvement activities in response to changes in the internal or external environment.
  • Performance improvement is laboratory wide.

Standard PI.2.30 requires each accredited organization to define "sentinel event" for its own purposes in establishing mechanisms to identify, report, and manage these events. Accredited organizations are expected to identify and respond appropriately to all sentinel events.