A-181 Comparison of POCT Accreditation Between TJC and CAP: Which Way to Go?

Abstract

Abstract Background Point-of-care testing (POCT) at UW Health University Hospital is accredited by the Joint Commission (TJC) while the main laboratory is accredited by the College of American Pathologists (CAP). Consolidating to a single accrediting agency would eliminate the burden of maintaining two separate accreditation programs, and reduce related expenses. In consideration of consolidation, we compared the accreditation requirements between the two agencies for POCT. Methods CAP standards in the All Common (n = 84), POC (n = 62), and Lab General checklists (n = 98) were evaluated for non-waived testing requirements in accordance to the POC test menu. The POC test menu includes the following non-waived tests: activated clotting time, blood gases, urine specific gravity by refractometry, and Tzanck smear; and provider performed microscopy (PPM): wet mount (skin or hair), wet prep, and fern test. A gap analysis was conducted to distinguish differences between CAP and TJC standards and further investigation was initiated when needed. Results The majority of CAP checklist standards aligned with the current processes under TJC. From the CAP All Common checklist, 5 out of 84 standards flagged as a potential gap. One notable difference was found for CAP COM.04250Comparability of Instruments and Methods—Nonwaived testing where comparison studies are required only for instruments and methods under the same CAP number. In contrast, the TJC requires instrument and method comparisons across the entire organization, regardless of separate CLIA certificates or sites. Shifting POC nonwaived tests to CAP would eliminate the need to perform comparisons across different sites, which in our hands has been labor intensive and of little clinical value. From CAP POC checklist, 10 out of 62 standards flagged as potential gaps. Specifically, CAP POC.03800Problem Resolution where the ability to provide prompt resolution for POC issues for all shifts in which POC testing is performed is demonstrated. From the CAP Lab General checklist, 4 out of 98 standards flagged as a potential gap. Specifically, CAP GEN.40470Specimen Collection Training where additional discussion with nursing education would be needed to assess collection training records. The other key difference was with CAP GEN.23584Interim Self-Inspection where self-inspection is required during the interim year. Conclusion Overall, our assessment is that moving non-waived POC testing to CAP will align the requirements for this set of largely hospital based POC tests, where the considerable effort saved from eliminating organization wide instrument/method comparisons could be more effectively applied to expanding our existing CAP mandated interim self-inspections to include nonwaived POCT. Because the vast majority of the waived testing performed at our organization occurs at ambulatory sites under CMS oversight, leaving waived POC tests under TJC oversight was felt to align better. Overall, the POCT requirements under CAP checklists were similar to TJC with minor, but potentially impactful, differences. In our situation, moving nonwaived POC testing to CAP accreditation and keeping waived POC testing under TJC accreditation provided the best balance between quality/patient safety and regulatory administrative effort.