There has been some confusion regarding the ASHI agreement with JCAHO. ASHI wishes to provide you with some clarification. JCAHO has two types of cooperative agreements with accrediting agencies: Comparative Agreements and Complementary Agreements.
Both types of agreements require the following of the Accrediting Agency:
- Be non-profit
- Accredit at least 100 organizations throughout the country
- Be recognized by state or federal agencies as having a comprehensive product
- Have on-site survey cycle of three years or less
- Agree to maintain an approach to public disclosure of organization findings comparable to JCAHO’s approach
- Have customer base that is common with JCAHO’s
The ASHI accreditation program meets all of the above criteria
Comparative Agreements
The accrediting body must have overall comparability with the JCAHO standards, survey processes, and accreditation policies. These include random unannounced inspections. Since the ASHI accreditation covers only one specialty of the entire laboratory, our standards cannot be considered as comparable in scope to JCAHO. We also do not have random unannounced inspections. For these reasons, we do not meet the criteria for a Comparative agreement.
Complementary Agreements
Entities that focus more on the technical or clinical aspects of departments or services are eligible for Complementary agreements by covering additional or more detailed aspects of the specialty. The standards and survey process of the complementary accrediting agencies are more focused on the technical and clinical aspects of the department or service within a health care organization and are not applicable to the entire organization. JCAHO could schedule a visit to an ASHI-accredited laboratory during a triennial survey and all applicable JCAHO standards could be assessed for compliance during such visits.
During a JCAHO inspection, the institution is being inspected. If, during the course of the audit, the laboratory is included in the scope of the inspection, then the laboratory must comply with any requests made during a JCAHO inspection.
ASHI Laboratories and JCAHO
A laboratory that is part of a JCAHO-accredited institution may be inspected by the JCAHO Accreditation program or by an accrediting agency that has a comparative agreement with JCAHO. The ASHI standards encompass what is outlined in the JCAHO standards and any changes to the JCAHO standards are provided to the ASHI QAS committee to determine if revisions to the ASHI standards are required. Therefore, an ASHI laboratory should meet all the standards required by JCAHO and this should be taken into consideration during the inspection by JCAHO or an accrediting agency with comparative agreement with JCAHO.
