| 4.1 |
Impartiality: identification and control of threats to impartiality, monitoring of personnel relationships |
Impartiality policy
Threat monitoring procedure
Conflicts of interest register
|
| 4.2 |
Confidentiality: management of patient information, controlled disclosure, personnel responsibility (4.2.1 to 4.2.3) — aligned with HIPAA Privacy Rule |
Confidentiality management procedure (HIPAA)
Confidentiality agreement template
|
| 4.3 |
Patient-related requirements: informed consent, public information, incident disclosure, non-discrimination |
Informed consent procedure
Patient information template
Incident disclosure procedure
Non-discrimination policy
|
| 5.1 — 5.2 |
Legal entity and laboratory director: competence, responsibilities, documented delegation. Laboratory director must meet CLIA-defined qualifications (high or moderate complexity testing). |
Legal entity document
Laboratory director job description (CLIA-aligned)
Delegation procedure
|
| 5.3 |
Laboratory activities: defined scope, conformity to requirements, advisory activities to users (clinicians) |
Scope of activities
Advisory procedure (5.3.3)
|
| 5.4 |
Structure and authority: organization, lines of authority, roles, quality manager authority |
Laboratory organizational chart
Quality manager job description
|
| 5.5 |
Objectives and policies: quality policy, measurable objectives, quality indicators (QI) across all 3 phases (pre-/examination/post-) |
Quality policy
Quality objectives document
QI dashboard
|
| 5.6 |
Risk management: identification of patient risks and improvement opportunities (linked to ISO 22367) |
Patient risk procedure
Risk mapping
|
| 6.2 |
Personnel: competencies, authorization, continuing education, personnel records (6.2.2 to 6.2.5). Includes CLIA-defined roles for high/moderate complexity testing. |
Competency matrix (CLIA roles)
Personnel management procedure
Continuing education plan
Personnel file template
|
| 6.3 |
Facilities and environmental conditions: access control, storage, specimen collection areas (privacy, ADA compliance) |
Facility management procedure
Storage procedure
Environmental monitoring
|
| 6.4 |
Equipment: selection and acceptance, instructions, maintenance, FDA MedWatch incident reporting, equipment service log |
Equipment management procedure
FDA MedWatch reporting procedure
Service log template
|
| 6.5 |
Calibration and metrological traceability: NIST-traceable calibration chain to SI or highest possible reference (ISO 17511) |
Calibration procedure
NIST traceability procedure
|
| 6.6 |
Reagents and consumables: receipt, lot acceptance testing, inventory management, incident reporting |
Reagent management procedure
Reagent incident reporting procedure
|
| 6.7 |
Service agreements: agreement with users / clinicians (6.7.1), agreements with POCT operators (6.7.2) |
Standard agreement with users
Standard agreement with POCT operators
|
| 6.8 |
Externally provided products and services: reference laboratories and consultants (6.8.2), review and approval of external services. FDA-cleared assays vs LDT distinction. |
Reference laboratory evaluation procedure
External service approval procedure
|
| 7.2 |
Pre-examination: patient/user information, examination request, primary specimen collection, transport, receipt, exceptional acceptance |
Patient/user info manual
Examination request procedure
Specimen collection manual
Sample transport procedure
Sample receipt procedure
Exceptional acceptance procedure
|
| 7.3 |
Examination processes: selection, verification (FDA-cleared assays), validation (LDTs), measurement uncertainty (MU), reference intervals, IQC with Westgard rules, EQA/PT, comparability |
Method selection procedure
Verification procedure (7.3.2)
Validation procedure for LDTs (7.3.3)
Verification/validation file template
Measurement uncertainty procedure (7.3.4)
Uncertainty calculation template
Reference interval procedure
IQC procedure (7.3.7.2)
EQA/PT procedure (7.3.7.3)
Comparability procedure (7.3.7.4)
|
| 7.4 |
Post-examination: review and release, critical results, automated reporting, report content (7.4.1.6), amendments, post-examination retention |
Review & release procedure
Critical results procedure
Automated reporting procedure
Examination report template
Report amendment procedure
Post-examination retention procedure
|
| 7.5 |
Nonconforming work: stop testing in case of patient risk, clinical impact assessment, decision on acceptability |
Nonconforming work procedure
|
| 7.6 |
Data control and LIS: LIS validation, downtime contingency plan, cybersecurity (HIPAA Security Rule) |
LIS control procedure
IT contingency plan
|
| 7.7 |
Complaints: publicly available process, tracking and recording, impartial resolution |
Complaint management procedure
Complaint form template
|
| 7.8 |
Business continuity and emergency preparedness: coordinated plan, procedures, periodic testing (new in 2022) |
Business continuity plan
|
| 8.1 — 8.4 |
Management system: quality manual, document control, records control |
Laboratory quality manual
Document control procedure
Master document list
Records management procedure
|
| 8.5 — 8.7 |
Actions on risks and opportunities, continual improvement, patient/user/staff feedback, nonconformities and CAPA |
Risks and opportunities procedure
Continual improvement procedure
Patient/user feedback procedure
NC and CAPA procedure
|
| 8.8 |
Evaluations: quality indicators, internal audits programmed on risk-based criteria |
Internal audit procedure
Annual audit program
Sub-clause audit checklist
Audit report template
|
| 8.9 |
Management review: required inputs, outputs, traced actions |
Management review procedure
Management review minutes template
|
| Annex A |
POCT / Point-of-Care Testing: governance (A.2), POCT quality assurance program (A.3), POCT training program (A.4) |
POCT governance procedure
POCT QA program
POCT training program
POCT IQC procedure
|
| CLIA & CAP |
US accreditation requirements: CLIA certification (waived / moderate / high complexity), CAP / A2LA / ANAB checklist alignment, deficiency citation handling |
CLIA scope management procedure
CAP, A2LA, or ANAB assessment procedure
Deficiency handling procedure
ISO 15189 ↔ CAP checklist matrix
|
| HIPAA & data |
US health data compliance: HIPAA Privacy & Security Rules, breach notification, 21st Century Cures Act, records retention |
HIPAA Privacy Rule procedure
HIPAA Security Rule procedure
Breach notification procedure
Information blocking compliance procedure
Records retention procedure
|
| Not included |
Documents specific to each laboratory examination — which must be written case by case by your laboratory, based on your accreditation scope and your analyzers |
Verification files per assay
Manufacturer technical sheets (per reagent)
Uncertainty calculations per analyte
IQC dashboards per analyte
Filled-in PT reports (per provider)
Analyzer operating procedures (per model)
|