Release Date: Mar 18, 2024

SHELTON, WA – Mason Health patients can rest assured that the level of care they receive from Mason Health’s Laboratory Department remains the highest standard in health care. In February, the Lab Department once again received accreditation from The Joint Commission, one of health care’s largest accreditation organizations. The Lab was found to be compliant in about 1,000 standards, after three full 10-hour days of observation, or survey days, in December 2023. The survey days are unannounced every two years, and come as a surprise to staff and leadership, who are told to expect the visit at some point in a three-month window. Over the past several inspections, the Joint Commission has typically arrived in March, making arrival in December an early surprise.

This accreditation renewal was the first for Laboratory Manager Lindsay Roberts in her current role. Typically, after the survey is complete, the Commission sends a list of citations to the department, and the department is required to respond to each citation with an action plan before receiving accreditation.

“Ultimately, with 1,000 standards, you do expect to see some citations, which is ideal — you want to have something to improve on that you can work on,” Roberts said. “However, I was very proud of our team this year. We had 11 citations and all of them were what I would describe as ‘easy fixes’ and involved educating the departments that we work with, rather than these large, systemic issues that are harder to change. Overall, it was very easy for us to address the citations.”

The survey focuses on the Laboratory, however, since the Lab interacts with multiple departments, there are observations that take place throughout the organization. For example, the survey looks at how nurses handle the point-of-care, staffing levels in Respiratory Therapy, how the Surgery Department handles tissues, and how the Environmental Services Department disposes of needles.

Mason Health received zero high-risk citations. Roberts turned in her action plans in early February and received notice of the accreditation soon after. Some changes that will be taking place include scanning every piece of patient paperwork into an electronic system, as opposed to saving and storing paper copies at Mason Health’s storage facility.

Labs must be accredited to be able to stay open in the U.S and in the state of Washington.

“I attribute our success to team morale and collaboration,” said Roberts, who has worked as Lab Manager since November 2022. “There is a cohesiveness in our team. It definitely takes the whole team.”

Mason Health, Public Hospital District No. 1 of Mason County is ISO 9001 Quality Management System certified by Det Norske Veritas (DNV) and is a licensed and accredited acute care hospital with a level four emergency trauma designation. Mason General Hospital and Mason Clinic are ENERGY STAR® certified and Mason Health is the recipient of three Practice Greenhealth Partner for Change Awards and a Greening the OR Environmental Excellence Award. There are more than 100 physicians on staff in 19 specialties. For more information or to find a health care provider, visit To learn more about DNV, visit


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Laboratory Manager Lindsay Roberts