Joint Commission Operational Standards

Safety Data Sheets (SDS)

• Include chemical's name, trade names, synonyms, manufacturer's information, handling, storage, and emergency procedures.

Operational Standards

• The Joint Commission accredits and certifies healthcare organizations in the U.S.
• Focuses on continual improvement of patient safety and quality of care.
• Updates standards regularly to reflect advances in healthcare and medicine.
• More than 250 hospital accreditation standards, including patients' rights and education, operational improvement, and National Patient Safety Goals (NPSGs).
• NPSGs require validating patient identification using a two-factor method.

Patient Safety and Identification

• Confirm patient identification by matching the wristband to the medical record and asking patients to state their name.
• Refer to the study guide addendum on the NHA website for details on CLSI guidelines for patient identification specific to specimen collection.

Safety and Compliance

• Patient safety is a top concern in healthcare facilities, along with employee safety.
• Regulatory bodies promote health and welfare of patients and workers, including OSHA, The Joint Commission, College of American Pathologists, CLSI, and CDC.
• Agencies develop protocols and regulations to ensure high-quality care and accurate test results.

Clinical and Laboratory Standards Institute (CLSI)

• Committed to providing high-quality care by developing standards and guidelines for laboratory accreditation.
• Works with industry and healthcare professionals to ensure up-to-date information and safest methods for blood testing.
• Provides guidelines for phlebotomists to achieve better patient care and accuracy in blood testing, including venipuncture, dermal puncture, and safety.

Order of Draw for Venipuncture

• Follows specific guidelines for filling multiple tubes of blood, including yellow-top tubes, light blue-top tubes, serum tubes, green-top tubes, purple-or lavender-top tubes, and grey-top tubes.

Objectives

• Explain regulations regarding workplace safety.
• Describe regulations regarding operational standards.
• Adhere to HIPAA regulations regarding protected health information (PHI).
• Describe the scope of practice and comply with ethical standards applicable to phlebotomy.

Regulations That Affect Laboratory Personnel

• OSHA regulates workplace safety, including exposure to biologic hazards and hazardous chemicals.
• The Bloodborne Pathogens Standard protects phlebotomists from exposure to body fluids.
• Implement work practices and engineering controls to prevent exposure incidents.
• Use personal protective equipment (PPE) and provide hepatitis B immunization for at-risk employees.

HIPAA Regulations

• Patients have the right to protection of personal information, including protected health information (PHI).
• PHI includes patient demographic information, treatment, medications, and diagnostic testing.
• Keep health information private and protect it from unauthorized access.
• Exceptions include health care staff with a direct need for the information and legitimate involvement in the patient's care.

Safety Data Sheets

• Safety Data Sheets (SDS) provide information on the safe handling, use, storage, and disposal of hazardous chemicals.
• SDS include the chemical's name, trade names, and synonyms, as well as the manufacturer's name, address, and emergency telephone numbers.
• They also provide information on handling and storage, and actions to take in case of accidental exposure.

Operational Standards

• The Joint Commission accredits and certifies thousands of health care organizations in the US.
• The Joint Commission focuses on continual improvement of patient safety and quality of care.
• There are over 250 hospital accreditation standards, addressing areas such as patients' rights and education, and operational improvement.
• The National Patient Safety Goals (NPSGs) program requires validating patient identification using a two-factor method.
• NPSGs emphasize the need for active communication between healthcare professionals and providers.

Regulations that Affect Laboratory Personnel

• OSHA has established regulations and guidelines to direct phlebotomists to work at the highest level of safety possible.
• The Bloodborne Pathogens Standard protects phlebotomists and other healthcare professionals from exposure to body fluids.
• The standard requires implementation of work practices and engineering controls to prevent exposure incidents.
• It provides guidelines for training for all employees who handle body fluids and addresses the use of personal protective equipment (PPE).
• The hepatitis B immunization is available for all at-risk employees.

Workplace Safety

• OSHA strictly regulates workplace safety, including exposure to biologic hazards and hazardous chemicals.
• Employers and employees must adhere to OSHA regulations to ensure workplace safety.

Patient Safety and Compliance

• Patient safety is one of the most important concerns in every health care facility.
• Several regulatory bodies, including OSHA, The Joint Commission, College of American Pathologists, CLSI, and CDC, promote the health and welfare of patients and workers.
• These agencies develop protocols and regulations to ensure high-quality care and accurate test results.
• They also work to establish guidelines that encourage health professionals to use safety measures to detect problem areas and find solutions.

Additional Regulations

• The Clinical Laboratory Improvement Amendments (CLIA) and Good Laboratory Practice are regulations that promote patient safety and high-quality care.
• The Needlestick Safety and Prevention Act regulates needle safety and prevention.
• The National Accrediting Agency for Clinical Laboratory Science offers program accreditation and approval, consultation, and continuing education in clinical laboratory sciences.