The Accreditation Process

Accreditation surveys are conducted on a two-year cycle. The typical general hospital laboratory accreditation survey usually lasts two (2) days, but may vary based on the size of the laboratory and the scope of testing performed. Laboratories new to the HFAP program will be given a two week notice of the survey date for the initial survey. All subsequent re-surveys will be unannounced.

The survey team composition may vary according to the laboratory’s services. However, the team usually consists of a Pathologist (Team Captain) and two Medical Technologists, all volunteer surveyors. Each team member brings expertise and a willingness to share their knowledge and experience with the laboratory. The team will assess all phases of the laboratory operation, from the pre-analytic to analytic to the post-analytic. Evaluation of compliance with the regulations, education, and peer review are accomplished in a manner that is informative and respectful.

Following receipt of the formal document listing the deficiencies cited during the survey, the laboratory has 30 days to respond to HFAP with documentation of corrective action(s).

The Bureau of Healthcare Facilities Accreditation (BHFA) will evaluate the laboratory’s on-site survey report and progress report (laboratory’s response to cited deficiencies) and may grant accreditation, limit accreditation to specific specialties/ subspecialties, defer accreditation pending correction of deficiencies, or deny accreditation. The laboratory will receive a HFAP Certificate of Laboratory Accreditation for each unique CLIA number surveyed. The facility will also receive a list indicating the specialties and subspecialties for which the laboratory (ies) (each unique CLIA number) is accredited to perform. Accreditation is granted for a 2-year period based on the date of the actual on-site survey.