CLIA Laboratory Director

CLIA Requirements and Responsibilities for Laboratory Directors

High Complexity Laboratory Requirements

  1. Licensed MD/DO/DPM AND certified in anatomic or clinical pathology OR 1 year of lab training during medical residency OR 2 years experience directing or supervising high complexity testing
  2. Doctoral degree in a chemical, physical, biological, or laboratory science AND certified by an HHS-approved board OR prior to 02/24/2003, served as Lab Director AND 2 years lab training or experience AND 2 years experience supervising or directing high complexity testing
  3. Prior to 02/28/1992, qualified as Lab Director under state law or Medicare lab regulations

Moderate Complexity Laboratory Requirements

  1. Licensed MD/DO/DPM, AND certified in anatomic or clinical pathology, OR lab training or experience consisting of 1 year directing or supervising non-waived tests, OR Beginning 09/01/1993, have earned at least 20 CME credits in laboratory practice addressing director responsibilities, OR training equivalent to 20 CME credits obtained during medical residency
  2. Doctoral degree in laboratory science AND certified by an HHS-approved Board, OR have 1 year experience directing or supervising non-waived testing
  3. Master’s degree in lab science AND 1 year lab training or experience AND 1 year of experience supervising non-waived testing
  4. Bachelor’s degree in lab science AND 2 years lab training or experience AND 2 years experience supervising non-waived testing
  5. Prior to 02/28/1992, qualified as Director

Responsibilities

  1. Ensure that policies and procedures are established for monitoring individuals who conduct pre-analytical, analytical, and post-analytical phases of testing to verify that they maintain competency:
  2. Ensure that all personnel have the appropriate education and experience prior to testing patient specimens; receive appropriate training for the type and complexity of services offered; and have demonstrated that they can perform all testing opera- tions reliably to provide and report accurate results
  3. Employ a sufficient number of laboratory personnel with appropriate education, experience and/or training to provide appropriate consultation, properly supervise, and accurately perform tests and report test results
  4. Ensure that laboratory personnel are performing the test methods as required to obtain accurate and reliable results
  5. Ensure that an approved procedure manual is available to all personnel
  6. Ensure that consultation is available to the laboratory’s clients on matters relating to the quality of the test results reported and their interpretation concerning specific patient conditions
  7. Ensure that test result reports include pertinent information required for interpretation.
  8. Ensure verification procedures are adequate to determine accuracy, precision, and other pertinent performance characteristics of the method
  9. Ensure test methods selected have the capability of providing quality results
  10. Ensure testing systems provide quality laboratory services across the path of work- flow (for all phases of testing: pre-analytic, analytic, and post-analytic phases)
  11. Ensure that the physical plant and environmental conditions are appropriate for the testing performed and provide a safe environment, free of physical, chemical, and biological hazards
  12. May direct no more than five labs
  13. Must be accessible to the laboratory to provide onsite, telephone, or electronic con- sultation as needed
  14. Verify that all delegated duties are properly performed
    1. To process specimens
    2. Perform test procedures
    3. Report test results promptly and proficiently
    4. Whenever necessary, identify remedial training and/or continuing education needs to improve skills
  15. Have a written list of responsibilities of each individual in the laboratory that specifies:
    1. The level of activity each is authorized to perform,
    2. Whether supervision is required for specimen processing, test performance or results reporting
    3. Whether consultant or director review is required prior to reporting patient test results
  16. Ensure that a general supervisor provides on-site supervision of certain testing personnel who perform high complexity testing
  17. Ensure that the laboratory is enrolled in an approved proficiency testing (PT) program Ensure that PT samples are tested in the same manner as patient samples
  18. Ensure that PT samples are tested in the same manner as patient samples
  19. Ensure that PT samples are tested in compliance with regulations that prohibit referral of specimens and sharing of or communication about results
  20. Ensure that PT results are returned on time to the PT program
  21. Ensure that PT results are reviewed by the appropriate staff, and the corrective action plan is followed when PT results are found to be unsatisfactory
  22. Ensure that quality control and quality assessment programs are established and maintained to identify failures in quality as they occur
  23. Ensure the establishment and maintenance of acceptable levels of analytical performance for each test system
  24. Ensure that corrective actions are taken and documented, whenever significant deviations from the laboratory’s established performance characteristics are identified, and patient test results are reported only when the system is functioning properly