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Loyola Medical Laboratories
Laboratory Waived Testing Program
This slide presentation includes an overview of:
• Loyola Medical Lab’s Waived Testing Program
• Federal Laboratory Regulations
• Good Laboratory Practices
• General Quality Assurance Requirements for all Tests
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Loyola Medical Laboratories
Laboratory Waived Testing Program
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Loyola Medical Laboratories
Laboratory Waived Testing
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Loyola Medical Laboratories
Laboratory Waived Testing Program
As a service to it’s clients, Loyola Medical Laboratories provides
technical assistance in the form of a Laboratory Waived Testing
Program created and supported by the section of Outreach Services.
The Laboratory Waived Testing Program was created to establish
standards for all waived testing performed at LUHS in an effort to
ensure quality patient testing and compliance with federal
laboratory laws.
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Loyola Medical Laboratories
Laboratory Waived Testing Program
The Outreach Services Section of
the Clinical Laboratory is always
looking for better ways to help our
clients. We are always willing to
answer any questions or help with
any problems regarding waived
testing here at LUMC.
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Loyola Medical Laboratories
Laboratory Waived Testing Program
The Outreach Services Section of the Clinical Laboratory does
the following to ensure quality patient testing and regulatory
compliance here at LUHS:

Coordinates the Point-of-Care Testing Committee. This committee
has the responsibility of regulating all Point-of-Care laboratory
testing here at LUHS and it’s outpatient and satellite facilities. Any
area which would like to perform new testing must submit an
application to this committee for review.
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Loyola Medical Laboratories
Laboratory Waived Testing Program

Created and supports a Procedure Manual for Laboratory
Waived Testing which is provided to all areas performing
waived testing.

Reviews new test methodologies and instruments for use at
LUHS. Performs all necessary testing required by law prior
to the implementation of any new test to ensure accuracy.
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Loyola Medical Laboratories
Laboratory Waived Testing Program

Provides instruction and technical assistance for performing
waived tests here at LUHS through classes, training checklists
and slide presentations.

Provides information and assistance with federal laboratory
laws and JCAHO compliance.
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Where to get Technical Help
The Laboratory Procedure Manual - Waived Tests
For any information about waived testing procedures
performed in your area, you should consult the
“Laboratory Procedure Manual
- Waived Tests”.
This is a large, royal blue binder given
to all sites who perform waived testing
under the laboratory’s license.
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Where to get Technical Help
The Laboratory Procedure Manual for Waived Testing
The Waived Testing Procedure manual contains:
• Written procedures for each test
• JCAHO regulations
• Required quality assurance for all tests
• Training checklists for all tests
• Sample competency logs for maintaining annual competency
• Helpful articles about CLIA and JCAHO regulations
• Master quality control logs for all tests
• Troubleshooting help
• Supply and ordering information
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Understanding Federal Laboratory Regulations
While federal laboratory regulations may not be as exciting
as a fireworks display,
it is important to understand what is required of you to
comply with federal laws and JCAHO standards. This
slide presentation will try to give you an overview of what
the federal laboratory laws require and why they are
necessary.
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Understanding Federal Laboratory Regulations
All laboratory testing is governed by a federal law called CLIA.
Clinical Laboratory
Improvement Amendments of 1988
These laws are administered by HCFA (the Health
Care Financing Agency) which is the federal agency
that oversees Medicare regulations and funding.
Any area that performs laboratory testing for clinical
use must abide by federal CLIA laws or risk removal
of Medicare funding to the facility.
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Understanding Federal Laboratory Regulations
CLIA was:
- enacted in 1988 to standardize and enforce good laboratory practices
- created to ensure that patient test results were reported accurately
CLIA goals are accomplished by:
- establishing basic standards of quality assurance
- requiring personnel training and competency
- requiring patient test result documentation and record retention
- requiring the performance of quality control for all tests
- requiring two year inspections for all areas performing testing
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Understanding Federal Laboratory Regulations
CLIA regulates all areas that perform testing for clinical use. Areas
such as clinical laboratories, satellite facilities, nursing units, mobile
health units, and even free testing in shopping malls are all covered
under CLIA laws and all must abide by the established regulations.
When establishing regulatory requirements for laboratory testing,
HFCA recognized that all laboratory tests are not equal. Some are
very simple to perform and some are more difficult and need special
training. To accommodate this, HCFA had the CDC classify all tests
that were on the market and all new tests into categories based on
their complexity.
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Categories of laboratory testing under CLIA
These complexity categories were determined using these criteria:
• Risk of erroneous result on patient health
• Degree of knowledge needed to perform the test
• Training and experience required
• Complexity of reagent and material preparation
• Complexity and number of operational steps to perform the test
• Calibration requirements
• Troubleshooting and maintenance requirements
• Degree of interpretation and judgment required to report results
• Availability of proficiency testing materials
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Purchasing a CLIA certificate (license)
In addition to following CLIA regulations, any area that
performs laboratory testing must purchase or be covered
under a certificate (license) to perform testing. One
certificate can be purchased to cover multiple areas at one
address. Areas with different street addresses must
purchase separate certificates.
To purchase a certificate, an application must be completed
and sent to the IDPH (Illinois Dept. of Public Health) who
administers HCFA’s CLIA laws here in Illinois.
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Purchasing a CLIA certificate (license)
One of four types of certificates must be purchased to
comply with CLIA regulations. An area performing testing
must purchase a certificate that covers the highest
complexity level of test that they perform. For example, if
10 waived tests are performed and one moderate
complexity test, a moderate certificate must be purchased.
Only the highest level of certificate must be purchased. For
example, the moderate level certificate will cover moderate
complexity tests and all waived tests. These certificates are
offered by test complexity level and include the following:
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Waived Testing Certificate
This category contains tests that are simple and don’t
require a high degree of educational background to
perform. Waived tests include such instruments and/or
tests as glucometers, urinalysis strips, some Strep A tests,
pregnancy tests, hemoglobin testing, etc. This category is
called “waived” because many regulations have been
“waived” or deemed not necessary since the tests in this
category are considered simple. Even though waived tests
are simple to perform they still require basic quality
assurance such as training, annual competency, quality
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control, etc.
Moderate Complexity Certificate
This category contains tests that require more educational
skills, more complicated steps or can cause a greater
degree of harm to a patient if performed incorrectly. This
complexity level has more stringent regulatory
requirements than waived.
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High Complexity Certificate
This category contains tests that are generally
performed only in large hospital or reference
laboratories by degreed Clinical Lab Scientists or
technicians. This level has the most stringent regulatory
requirements.
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PPM Certificate
In addition to these complexity categories, there is an
additional sub-category called PPM or Provider
Performed Microscopy. This category is considered a part
of the moderate complexity category but is accorded
special considerations by CLIA. This category contains a
small group of tests that are performed as part of a
physical exam by physicians, dentists, nurse midwives,
physician assistants or nurse practitioners.
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PPM Certificate
The tests under this category are not subject to a routine
two year inspection but basic quality assurance such as
training, quality control, competency, proficiency testing,
etc. are still required. This license can only be purchased if
testing is performed by the above personnel and only for a
small group of tests. This certificate will also cover all
waived tests since it is considered a sub-category of a
moderate complexity certificate.
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Tests included in the PPM category
• Fern testing
• Qualitative (not quantitative) sperm analysis
• KOH preps
• Pinworm exams
• Urine sediment examinations
• Nasal smears for granulocytes.
• Direct wet mounts for presence of bacteria, fungi, parasites &
human cellular elements.
• Fecal leukocyte exams
• Post coital direct, qualitative exams of vaginal or cervical mucous
Testing under this license is allowed ONLY if performed by the
specified personnel. If staff nurses or technologists perform testing, a
moderate complexity license must be purchased and two year
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inspections are required.
Understanding Federal Laboratory Regulations
When CLIA was enacted, the federal government realized that they
did not have the resources to perform an inspection every two years
for all areas performing laboratory testing.
To remedy this, they allowed organizations to be “deemed” by
HCFA to inspect facilities and report the results back to the agency.
Many organizations that were already performing inspections
applied to HCFA for deemed status. In order to inspect under the
CLIA ‘88 laws, each organization had to submit their inspection
standards for review. By proving that their standards were equal to
or more stringent than the current CLIA ‘88 regulations, each
organization was then allowed to conduct inspections under24the
CLIA laws.
Understanding Federal Laboratory Regulations
When a CLIA license is purchased, the facility is allowed to choose
which organization will perform their two year lab inspection.
Two large organizations that were granted deemed status are:
- JCAHO (Joint Commission on Accreditation of Healthcare
Organizations) and
- CAP (College of American Pathologists)
Both of these organizations have been conducting inspections of
hospitals and laboratories for many years and have established their
own regulations and requirements.
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Understanding Federal Laboratory Regulations
At the Loyola Medical Center, the laboratory holds all CLIA
licenses for waived testing and is responsible for establishing
programs that facilitate compliance with CLIA laws.
Loyola Medical Labs holds a Waived Testing certificate for the
hospital and outpatient facilities and has selected JCAHO to
perform our inspection of waived tests.
Our Moderate and High Complexity Testing is inspected by CAP
(College of American Pathologists) in all areas.
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Understanding Federal Laboratory Regulations
When a facility chooses an organization that will perform
their laboratory inspections, they must abide by the
standards or regulations that are established by that
organization. For example, LUHS has chosen JCAHO to
inspect our waived testing program. Therefore, we must
abide by all standards that JCAHO has established to
regulate this category of testing.
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Good Laboratory Practices
Under CLIA, all categories of testing must meet basic good
laboratory practices in regards to quality assurance and safety. In
addition, if inspected by an outside agency (JCAHO, CAP), a lab or
area must adhere to any additional standards established for each
category by the inspecting agency. Some of these CLIA and
JCAHO requirements involve:

Patient test management - a system must exist for reporting,
documenting, and retaining patient results for legal reasons.

Quality control. A written quality control program must exist and
be enforced and quality control records must be retained for 2 years.
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Good Laboratory Practices

Quality assurance - must have a written QA program.

Procedures - must have written procedures for how to perform
the tests and procedures must be reviewed annually.

Personnel requirements - must meet CLIA established
educational requirements and must have an established training
and competency program. Documentation of training must be
maintained indefinitely.

Use of testing - the organization must define how tests are used
(either as a screening/monitoring or diagnostic test).
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Good Laboratory Practices


Proficiency testing. At this time this applies only to moderate
and high complexity testing. Each area must enroll in a program
in which “blind” samples are tested for accuracy. The results are
reported to HCFA and maintaining licensure depends on
successful performance.
Calibration and calibration verification of instruments - for
moderate and high complexity testing only.
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General Quality Assurance Requirements for All Tests
These are general QA standards that should be followed for all
laboratory waived tests:

Quality control procedures should always be performed according
to the written procedure. Quality controls MUST be performed
BEFORE testing patient samples (only exception are occult blood
cards where quality control is performed after the patient test).

Patient testing must never be performed using kits or reagents that
have failed quality control procedures.
 All
waived tests should be performed correctly according to written
instructions.
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General Quality Assurance Requirements for All Tests
 Staff performing testing must have documented training prior
to reporting all patient results.

Refrigerators or freezers where supplies are kept should be
monitored on a daily basis and a written record maintained for
JCAHO (thermometers should be NIST traceable and be able to
report the minimum and maximum temperatures reached since
the last reading was taken).
 Whenever
a new box, bottle, or kit is opened, the date opened
and the date it expires should be written on the box or bottle.
Reminder: once a control is opened, the expiration date is NOT the
date stamped on the bottle. Often, a 30 or 60 day expiration date
applies after opening.
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General Quality Assurance Requirements for All Tests
 Test
kits and controls should be stored according to manufacturer’s
instructions.

NEVER use expired kits or controls to perform testing. Using
expired kits can result in inaccurate patient test results being
reported. If the expiration date was not written on the item, or a
foil pack (example: pregnancy) was left opened and unused, use
the old adage:WHEN IN DOUBT, THROW IT OUT! Otherwise,
you may be wasting valuable time trying to make controls perform
or worse, you may report an inaccurate patient result.
 Always
properly identify patients prior to collection of blood or
other body fluids for testing.
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General Quality Assurance Requirements for All Tests
 Always
label blood tubes, urine specimens, throat cultures, etc.
Never assume you will label them later; this can lead to
unnecessary recollections and/or results reported on the wrong
patient!
 When
performing waived testing, always label any test device,
cassette, Hemoccult card, etc. into which a patient specimen is
introduced to test. If you leave an unlabeled test on the counter
and someone else does too, you may not know which is which!
 Always
document results of laboratory waived tests in the
patient’s medical record using established protocol for your area.
This is required by federal law!
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General Quality Assurance Requirements for All Tests
 Always
perform any maintenance such as cleaning that is
required on instruments prior to performing patient testing and
when required. A result is only as good as the instrument it is
performed on!

Use any and all information that is available to you - the
Laboratory Procedure Manual - Waived Tests and any
informational charts, posters, etc. These are provided to help
you.
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Waived Testing and Regulations
Review Questions
True or False answers
To see the answer, mouse click under the question.
1. It’s ok to use kits past their expiration date if it’s just a day or two.
False - kits should not be used past their expiration date.
2. When a control is opened, it always expires on the date that is
stamped on the bottle.
False - often, when a bottle is opened the expiration date changes to
30 or 60 days past the opening date.
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Waived Testing and Regulations
Review Questions
True or False answers
To see the answer, mouse click under the question.
3. All tubes of blood, test devices, aliquot specimens, etc. should be
labeled with the patient’s medical record number and/or name.
True - not labeling tubes, specimens, or test devices can lead to
patient recalls or worse, the wrong result reported on a patient.
4. You don’t need a certificate (license) to perform only waived tests.
False - a waived testing certificate is required to perform waived
testing.
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Waived Testing and Regulations
Review Questions
True or False answers
To see the answer, mouse click under the question.
5. Quality controls need only be tested when you think a patient’s test
result is incorrect.
False - quality controls (2 levels or positive and negative) must be
performed at least once every 24 hours that patient testing is
performed.
6. Training does not have to be documented - just performed.
False - all training and competency must be documented for JCAHO.
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Waived Testing and Regulations
Review Questions
True or False answers
To see the answer, mouse click under the question.
7. Annual competency is required for all staff performing laboratory
testing.
True - competency is a tool to review correct procedures and to
ensure that testing is being performed accurately.
8. Waived testing here at LUMC is inspected by JCAHO.
True
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Waived Testing and Regulations
Review Questions
True or False answers
To see the answer, mouse click under the question.
9. Medical technologists and staff nurses are allowed to perform PPM
tests under a PPM certificate.
False - only special personnel such as physicians, dentists, nurse
practitioners, physician assistants and nurse midwives are allowed
to perform testing under a PPM certificate. If medical
technologists or staff nurses perform PPM tests, the area must
purchase a moderately complex certificate.
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Waived Testing and Regulations
Review Questions
True or False answers
To see the answer, mouse click under the question.
9. Quality control should be performed and compared against
acceptable ranges before performing patient tests.
True - quality control MUST be performed and be acceptable before
performing ANY patient tests!
10. Competency must be performed annually for all waived tests.
True - JCAHO requires competency to be performed & documented.
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This concludes this presentation on Waived Testing and Regulations
Please refer any questions or problems to:
Geri Augustine BS MT(ASCP) CLS(NCA)
Technical Specialist - Near Patient Testing.
Loyola Medical Laboratories
Loyola University Medical Center
(708) 216 -8044 or x68044
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