Compliance with Point of Care Testing

Standard 06.05.04 Point of Care Testing relates to laboratory testing performed outside the laboratory and states:

When the facility performs blood gases or other laboratory tests in the respiratory care unit or any other location within the facility, they shall meet the applicable requirements for the general laboratory services.

This standard also applies to any other laboratory tests including any Point of Care (POC) tests performed in nursing or ancillary departments.

Laboratory Services is responsible for ensuring that the same standard of practice exists for laboratory tests across the organization, regardless of the location in which the test is performed or the person performing the test. Depending on the complexity of laboratory services provided and the number of points of access, it can be a challenge to have consistency and full compliance.

Because oversight of all POC testing is the responsibility of the laboratory, some hospitals have found great success in maintaining compliance by assigning an individual who reports directly to the laboratory manager to oversee all POC testing for the facility, regardless of type or location. This supports continuity of training, competency, and quality assurance for testing.

Under this solution, this designated individual would be responsible for ensuring that:

• all sites of POC testing have valid CLIA certificates.
• competency testing.
• quality control.
• monitoring and appropriate infection control practices for cleaning/maintaining/use of POC machines for patient care.
  
  

During survey, Surveyors would have a single point of reference to discuss areas where POC testing occurs to validate that all locations follow the policies of the laboratory and are reviewed by the laboratory manager for compliance with requirements for testing as defined on the applicable CLIA certificate.

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