Your Life, Your Health: SETMA's clinical lab accreditation renewed by Joint Commission

James Holly, M.D.

As most healthcare providers were preparing to celebrate the Declaration of Independence on July 4, Southeast Texas Medical Associates (SETMA) had a surprise laboratory inspection by the Joint Commission. Formerly known as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Joint Commission founded in 1949 is the oldest healthcare organization in the world.

For generations, the name and certainly the announcement of an unannounced and unscheduled visit by the Joint Commission were enough to strike fear and/or to create anxiety in any healthcare organization. A great deal of time and energy was spent upon satisfying the demands of the commission as accreditation was required to “stay in business” and to receive funding from Medicare and Medicaid. Sometimes organizations wondered whether this was exercise contributed to the success and excellence of their mission or not.

That has changed in the past decade as there are other options for accreditation, and the Joint Commission has changed its own culture to be less confrontational and more collegial without sacrificing its standards and requirements. Private medical practices have not been subject to accreditation requirements until recently and even now accreditation is optional.

SETMA began the process of accreditation in pursuit of Patient-Centered Medical Home (PC-MH) accreditation but quickly expanded that accreditation to ambulatory care and to clinical laboratory accreditation. SETMA began this process in 2009 and achieved its first accreditation for PC-MH in 2010 from the National Committee for Quality Assurance (NCQA) and accreditation for PC-MH and Ambulatory Care in the same year from the Accreditation Association of Ambulatory Health Care (AAAHC).

In 2013, SETMA renewed these accreditations from NCQA and AAAHC and in 2014 received accreditation for PC-MH and Ambulatory Care from URAC (Formerly known as the Utilizations Review Accreditation Committee) and from the Joint Commission. In 2016, SETMA renewed NCQA recognition for PC-MH and for excellence in Diabetes Care and Cardiac and Stroke Risk Care. Beginning in 2014, SETMA’s Clinical Laboratory has been accredited by the Joint Commission with renewals in 2016 and 2018.

It is this last laboratory accreditation by the Joint Commission that is the subject of this review.

Monday, July 2, the Joint Commission arrived at SETMA with only two hours’ notice. After a full, two-day review of SETMA’s clinical laboratory and visits to three of SETMA’s six clinical locations, SETMA achieved an overall score of 99.4 percent with only a few minor improvements needed to satisfy all of the Joint Commission laboratory standards.

Credit for this achievement belongs to Tiffany Wilkins, SETMA Laboratory supervisor; Kathy McBride, SETMA Laboratory director; Vincent Murphy, MD, and SETMA Laboratory medical director. The credit also belongs to the laboratory staff at the central laboratory at SETMA I and to each of the phlebotomists at all six SETMA locations and at all of the nursing homes and other facilities for whom SETMA provides laboratory services.

This excellent performance is built on the foundation which SETMA’s founders, partners and executive management established in 1995 when the decision was made to provide extensive laboratory services for patients seeking care at SETMA. This commitment included compliance with all national standards and using the finest equipment available and upgrading that equipment and frequently upgrading that equipment as often as necessary to maintain standards of excellence. This not only provided our patients with the convenience of having their laboratory work done at the same location as their clinical visit but when laboratory results were integrated with SETMA’s electronic medical record (EMR) in 1999 and when clinical support tools were deployed in 2000, the proved quality of care received at SETMA was established. Finally, in 2009, when SETMA began publicly to publish the results of quality metrics by provider name, the cycle of excellence was completed. This would not be possible without our integrated laboratory and ambulatory EMR.

In McBride’s report to SETMA, she reviewed the Joint Commission’s comments about SETMA’s laboratory:

1. Has a very small footprint for the work it performs.

2. Has an impressive menu of tests for a physician lab.

3. Joint Commission was extremely impressed with SETMA’s performance improvement activities, especially the patient driven ID of their own labels prior and post venipuncture to reduce mislabeled errors.

4. Laboratory staff work cohesively and very well as a team, including phlebotomists, outreach, and technologists. The Joint Commission was very, very observant and missed nothing!

5. The Joint Commission said, and I quote, “Your phlebotomists rock.”

McBride concluded, “SETMA should feel VERY proud of the work you do daily especially since this was an unannounced survey and we do what we do EVERY day!”

In response to the Laboratory Director’s summary, SETMA's CEO sent a note to all of SETMA’s staff in which he said:

“1. I hope everyone understands how beneficial Joint Commission Accreditation is for our laboratory, for ambulatory care and for patient-centered medical home.

2. Also, I hope that everyone understands how difficult Joint Commission Accreditation is to obtain and how difficult it is to maintain.

3. This is our third Joint Commission Accreditation cycle for our laboratory. Our medical home and ambulatory care Joint Commission Accreditation runs through 2020.

Kathy, you and your staff do us and make us proud. Thank you.”

Joint Commission and SETMA

Since our initial contact in 2014, SETMA and the Joint Commission have carried on a productive and beneficial dialogue about the accreditation process. In March 2014, the Commission commented, “I was just talking to one of my colleagues and showing him SETMA’s notebook which was prepared in response to the Joint Commission’s Standards and Requirements Chapter Seven on Leadership.” The executive said, “Look at this; everything they do is founded upon a philosophical foundation. They know ‘what they are doing,’ but more importantly, they know 'why they are doing it.’” This was a remarkable observation in that it cut to the heart of SETMA’s growth and development.

Eighteen months later, that dialogue had continued and SETMA’s philosophy was addressed. “Because we think accreditation is an important part of excellence in healthcare organizations, in oversight and compliance functions and, in quality improvement, we shared the below. The spirit of accreditors, which should be collegial and collaborative, is addressed, as is the value of accreditation. If accreditation and/or oversight deteriorates into an adversarial dynamic, the positive effects of that oversight can and will be lost. This is true for accreditation organizations and for compliance officers, whether governmental or other.”

The joint Commission said, “You note that ‘The provider must be an extension of the family. This is the ultimate genius behind the concept of Medical Home, and it cannot be achieved by regulations, restrictions and rules.’ Are you implying by this statement that there is no role for 'regs, rules, and restrictions,' or simply that they are insufficient to sustain long-term change?”

SETMA responded. “No doubt, as our accreditation efforts suggest, we believe that there is a key place for standards and guidelines. My point is directed at the government’s preoccupation with creating ‘change’ with demands and dictates. I have said to the ONC often, ‘If you demand that everyone must do the same thing, the same way, every time, you will eliminate creativity, generative thinking and transformation. Tell us what you want done and let us demonstrate our unique way of doing it. Then evaluate it and find the "best practice or best solution" and promote that.’

“When change is driven only by external demands, it is not sustainable and will become dependent upon rewards to drive improvement. But when change is driven by internalized values and vision, being self-sustaining and generative in nature, it is sustained not by financial or other rewards, but by the passion of the participants. For change to be permanent, it must be driven by transformation rather than reform. Transformation is driven by internalized value and vision. Rules, regulations and requirements can be part of an external standard against which you can measure yourself, but they will never become a part of the energy which sustains change."

The Joint Commission continued with the question, “Also, would you consider ‘standards’ (such as those that certain accrediting bodies use to be equivalent to 'regs, rules, and restrictions,' or do you see them as having value because they offer a blueprint that describes a desirable future state that is worth attaining/maintaining?”

SETMA responded, “As implied above, I think standards to be important guideposts in starting us on our pilgrimage and in giving us guidance in what to do, and, often, even, in how to do it. Remember Lincoln’s famous quote in his 1858, ‘House Divided’ address to the Republican National Convention. He said, ‘If we can first know where we are and whither we are tending; we can better judge what to do and how to do it.’ A healthcare GPS must tell you where you want to go – that is often expressed in standards, evidenced-based goals and quality outcomes – but if the GPS does not also tell you where you are – how far you are from where you want to be — you can never get to where you want to be.

“Standards are what we measure ourselves against, as we create our future. Remember Peter Senge’s great comment in ‘The Fifth Discipline’ as he addresses ‘creative tension,’ which is the difference between your ‘reality’ and your ‘vision.’ The ‘tension,’ which cries out for resolution, is created by standards which you have not yet met, but which you embrace as ‘the good.’”


Pressures and demands of medical practice can sometimes distract healthcare providers from their main mission. Standards and accreditations continue to challenge us to meet our own self-established standards and the measurement of our performance by others allows us to objectively know how well we are doing.

As SETMA approaches our 25th anniversary in 2020, we will maintain the standards of excellence we adopted decades ago and we will know that we continue to meet them as we continue to be measured by the Joint Commission and others.

Dr. James L. Holly is CEO of Southeast Texas Medical Associates, LLP (SETMA) in Beaumont.