The FDA's Final Rule on Laboratory Developed Tests (LDTs), published on May 6, 2024, represents the most significant regulatory change in the laboratory testing industry in decades. This shift from enforcement discretion to active regulation reflects the FDA's growing concerns about the complexity and widespread use of modern LDTs.
As a consulting partner offering a deep bench of laboratory and medical device professionals with extensive experience in both clinical and regulatory environments, we recognize the magnitude of this transition and its impact on laboratory operations.
This guide provides a detailed roadmap for achieving Stage 1 compliance by the May 6, 2025 deadline.
We also recommend watching the following webinar hosted by ARUP's Chief Medical Officer and Senior Director of Governmental Affairs, Jonathan Genzen, MD, PhD, and Chief Compliance Officer, Jonathan Carr, JD. It provides an excellent overview of the requirements included in the final rule and how these requirements differ across certain settings and types of testing.
A Brief Background
LDTs have historically occupied a unique position in the diagnostic landscape. Under the FDA's previous approach of enforcement discretion, these tests provided crucial diagnostic capabilities, particularly in areas where commercial products were unavailable. This discretionary approach stemmed from the traditional nature of LDTs as relatively simple tests performed on a small scale within single laboratories.
However, the landscape has evolved dramatically. Modern LDTs often represent sophisticated, high-volume testing operations that significantly impact patient care decisions. This evolution and growing concerns about test validation and performance have driven the FDA's decision to implement comprehensive oversight.
The Final Rule amends 21 CFR Part 809.3(a) to explicitly include LDTs in the definition of in vitro diagnostic products. This amendment clarifies that IVDs encompass all products intended for use in the collection, preparation, and examination of specimens from the human body, regardless of whether a traditional manufacturer or a laboratory produces them.
The FDA’s Phased Implementation Timeline
Recognizing the significant impact this regulatory change will have on laboratories, the FDA has established a phased implementation timeline.
This approach allows laboratories to adapt to the new requirements gradually over four years. (The FDA often officially refers to implementing these regulations as the phase-out of enforcement discretion. In other words, the “phase-out” of enforcement is a “phase-in” of regulatory requirements.)
Here's a quick look at the key dates and requirements:
Throughout this phased implementation, laboratories should continuously assess their LDT portfolio, prioritize resources, and develop a strategic plan to meet each deadline. It's crucial to start preparations early, particularly for high-risk LDTs requiring more extensive data and earlier submission deadlines.
Partial Exemptions and Targeted Enforcement Discretion
The FDA's Final Rule includes specific exemptions (carve-outs) for certain LDTs. These tests will face reduced regulatory oversight, including previously existing tests ("grandfathered" LDTs), as long as they haven't undergone significant modifications to their use, operation, technology, or safety specifications.
The exemptions also cover "1976-Type LDTs" — manual tests performed by specialists using legally approved components in CLIA-certified labs. Additionally, certain Human Leukocyte Antigen (HLA) tests used in transplant procedures are exempt when performed in qualified laboratories.
Several other categories receive this reduced oversight: forensic tests, military and VA tests, and tests approved by New York State's Clinical Laboratory Program. Healthcare systems can also develop tests for unmet patient needs when no FDA-approved alternative exists or isn't suitable. Finally, non-molecular blood typing tests for rare antigens are exempt when no alternatives are available, though this doesn't apply to molecular testing methods.
Below is a chart showing which tests are included and excluded in the phase-out.
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Click on the table or here to open it larger in a new window.
Tests excluded from the final rule
Notably, certain test types remain unaffected by the FDA's shift away from enforcement discretion. Essentially, the FDA anticipates that the following categories of devices will continue to adhere to the full medical device regulatory framework:
- Blood Donor Screening tests designed for screening blood donors or human cells, tissues, and cellular and tissue-based products (HCT/P) for infectious diseases.
- Tests intended for emergencies declared under §564 of the FD&C Act. In conjunction with the Final Rule, the FDA released a draft guidance on considerations for adopting enforcement discretion policies for unauthorized tests during future public health emergencies. Additionally, the FDA issued a second draft guidance on enforcement policy for specific tests intended for immediate public health response without a declaration under the emergency use authorization provisions at §564 of the FD&C Act. The Final Rule highlighted the significant issues caused by ineffective tests during the COVID-19 pandemic as a primary reason for maintaining regulatory oversight of these tests.
- Direct-to-consumer tests. As noted in the preamble to the LDT final rule, the FDA's general enforcement discretion has not been applied to tests intended for consumer use without "meaningful involvement by a licensed healthcare professional," due to the higher risks these tests pose to patients.
- LDTs included in the FDA's ongoing voluntary pilot program for certain oncology drug products.
The Stage 1 Compliance Challenge
For clinical laboratories, the transition from traditional quality systems to FDA-compliant reporting systems represents a significant operational challenge. While CLIA-certified laboratories already maintain robust quality programs, the MDR requirements demand a more structured approach to event reporting and investigation. Success requires understanding how these three core systems work together and building them with both compliance and practicality in mind.
The three required systems serve distinct but interconnected functions in ensuring test quality and patient safety:
- Medical Device Reporting focuses specifically on events that may have caused or contributed to death, serious injury, or significant malfunction, with mandatory 30-day reporting timelines.
- The correction and removal reporting system manages product modifications and withdrawals, requiring 10-day reporting for serious issues classified as Class 1 or 2 recalls.
- The complaint handling system serves as the foundation, capturing and documenting all quality-related communications while feeding relevant information to the other two systems.
Integration of all three systems is therefore crucial to successful implementation. These systems must work together seamlessly while maintaining their distinct regulatory requirements. Clear triggers must exist for escalating complaints to MDR evaluation or correction/removal assessment, supported by consistent documentation practices across all three systems.
It’s also important to acknowledge the resourcing challenges here. Clinical laboratories, while well-versed in CLIA compliance and quality management, face a fundamentally different challenge with FDA requirements that, in most cases not only justifies, but demands specialized consulting support. While CLIA focuses primarily on quality control and proficiency testing, FDA's systems require sophisticated risk assessment, complex decision-making frameworks, and specific documentation practices that more closely resemble medical device manufacturing than traditional laboratory operations.
- MDR systems require a nuanced understanding of what constitutes reportable events, with decision trees that can mean the difference between appropriate reporting and either over-reporting (creating unnecessary burden) or under-reporting (creating compliance risk).
- Corrections and removal decisions involve a careful assessment of health hazard evaluations and recall classifications that most laboratories have never encountered.
- Even complaint handling under FDA oversight differs significantly from typical laboratory incident management, requiring specific documentation elements and trending analyses that align with the FDA's enforcement approach rather than CLIA's quality improvement focus.
Experienced consultants bring not only knowledge of these requirements but also practical implementation strategies tested across multiple organizations, helping laboratories avoid common pitfalls while building sustainable systems that satisfy FDA expectations without overwhelming laboratory resources.
Contact us if the work projects we explain in the subsequent sections of this guide make it clear that your team requires expert third-party consulting support. We have the bench of contracted talent to help laboratories plan and execute all components of Stage 1 compliance.
Medical Device Reporting (MDR) — (21 C.F.R. Part 803)
At Stage 1, the FDA aims to systematically monitor significant adverse events to identify "problematic" LDTs in the market. Starting May 6, 2025, laboratories must comply with MDR requirements, which mandate reporting certain events to the FDA.
- A reportable event occurs when an LDT reasonably suggests it has or may have caused or contributed to a death or serious injury, or has malfunctioned in a way that would likely cause or contribute to a death or serious injury if the malfunction were to recur.
- A "serious injury" is defined as a condition that is life-threatening, results in permanent impairment or damage to body function/structure, or requires medical/surgical intervention to prevent permanent impairment.
- A "malfunction" means the failure of a device to meet its performance specifications or otherwise perform as intended.
Importantly, laboratories must report events even if they can only determine the LDT may have caused or contributed to a death or serious injury. Reportable events can include user errors, issues with materials or components, design issues, labeling issues, issues resulting from off-label use, or other malfunctions. Reporting an event does not constitute an admission that the LDT caused or contributed to the harm.
Here at the reporting timeframes at a glance:
- Standard reporting: Within 30 calendar days after becoming aware of a reportable event.
- Emergency reporting: Within 5 working days if remedial action is needed to prevent unreasonable risk or substantial harm to public health, or if FDA specifically requests a report.
- For recurring events, laboratories can request to submit quarterly summary reports instead of individual reports (for example, reporting failed runs caught by control failures).
The steps to compliance
Correction and Removal Requirements — (21 C.F.R. Part 806)
The FDA is requiring laboratories offering nonexempt LDTs to comply with correction and removal requirements as part of its broader effort to systematically monitor and identify "problematic" LDTs in the market. These requirements require that laboratories promptly report certain corrective actions and maintain comprehensive records of all corrections and removals, even those that don't require reporting.
A laboratory must submit a written report to the FDA when correcting or removing an LDT for two specific reasons:
- to reduce a health risk posed by the LDT, or
- to remedy any unlawful activity resulting from the LDT's use, such as improper labeling.
The FDA defines a correction as any repair, modification, adjustment, relabeling, destruction, or inspection (including patient monitoring) performed without moving the device from its point of use. A removal involves physically relocating the device to another location for any of these same actions.
Not all corrections or removals trigger reporting requirements. Actions taken solely to improve performance, quality, or profitability don't require reporting unless they address health risks or legal compliance issues. Furthermore, if an event has already been reported under MDR requirements, no additional report is needed.
However, when a correction or removal is undertaken to address health risks or legal compliance, laboratories must submit their report within 10 working days of initiating the action. Reports can be submitted via email to the FDA or through the ESG using eSubmitter.
Here are examples of when corrections or removals are required:
- When lab personnel errors result in incorrect test results being reported.
- When contaminated reagents affect multiple reported test results.
- When systematic issues require correction of previously reported results.
Here are examples of when corrections or removals are NOT required:
- When specimen collection errors occur at unaffiliated collection sites.
- When issues are caught before test results are reported.
- When errors stem from external systems not part of the LDT.
The steps to compliance
Complaint Files — (21 C.F.R. Part 198)
At Stage 1, laboratories offering nonexempt LDTs must comply with the FDA's Quality System complaint file requirements, establishing formal procedures for handling complaints. A complaint is defined as any written, electronic, or oral communication alleging deficiencies in a device's identity, quality, durability, reliability, safety, effectiveness, or performance after it is released for distribution. For LDTs, this typically involves reports of erroneous test results.
The laboratory must establish a formally designated compliance unit staffed by appropriately trained individuals. While this unit may be located separately from the laboratory, all complaint-related information must remain readily accessible. The unit must implement written procedures ensuring uniform and timely processing of all complaints, including proper documentation of oral complaints upon receipt and evaluation of whether additional adverse event reporting is required.
The complaint handling system serves two critical purposes: enabling laboratories to identify trends requiring further investigation and allowing the FDA to assess complaint processes during inspections. FDA recommends maintaining all complaint files related to an LDT in a single location to facilitate trend analysis. This centralized approach helps identify patterns that might indicate systemic issues requiring broader corrective actions.
Here's what every complaint file must include:
- Test identification
- Date complaint received
- Complainant's name, address, and phone number
- Nature and details of the complaint
- Investigation dates and results
- Corrective actions taken
- Any reply to the complainant
The steps to compliance
Examples of How These Systems Work in Practice
Consider the following real-world scenarios that laboratories may encounter.
Laboratory Processing ErrorsIf laboratory personnel inadvertently swap specimens during testing, resulting in Patient A receiving Patient B's results and vice versa, the incident triggers multiple regulatory obligations. This scenario requires recording as a complaint, thorough investigation, and potentially MDR reporting if the erroneous results may have caused or contributed to serious injury. For instance, in cancer diagnosis testing, where incorrect results could lead to unnecessary treatment for one patient and delayed treatment for another, MDR reporting would be required. The laboratory must also implement corrections and issue recalls of the original test reports, replacing them with corrected results. |
Pre-analytical ErrorsContrast the previous example with specimen collection errors occurring at an unaffiliated blood draw site. While the outcome may be similar — switched specimens leading to incorrect result reporting — the regulatory requirements differ. The laboratory must still document the complaint and conduct an investigation, but correction/removal reporting to the FDA is not required because the LDT itself functioned properly. This distinction highlights the importance of determining whether the error originated from the test system or from external factors. |
Information System IssuesModern laboratories rely heavily on Laboratory Information Management Systems (LIMS), creating another category of potential errors. Consider a case where the test performs correctly, but a defect in the validated commercial LIMS causes incorrect result reporting. This scenario requires complaint documentation and investigation. If the erroneous result could cause serious injury, such as in diagnostic testing that directs treatment decisions, MDR reporting would be necessary. However, since the commercial LIMS is not considered part of the LDT device, no correction/removal reporting or recall to the FDA is required. Here we see the need to clearly define the boundaries of the LDT device when determining regulatory obligations. |
Cross-System Integration and Implementation
Integration requires the development of a master process flow diagram showing how information moves between the three systems. This should include specific trigger points where complaints require escalation to MDR evaluation or correction/removal assessment.
The laboratory should create a comprehensive compliance calendar tracking all reporting deadlines and review requirements. This calendar should account for the various timing requirements: 30 days for MDR reporting, 10 days for Class 1 and 2 recalls, and internal timelines for complaint investigation and resolution.
Each phase should include specific deliverables, success criteria, and validation requirements before moving to the next phase. The laboratory should develop detailed test scenarios covering various potential situations, from simple complaints to complex events requiring multiple system interactions.
Training programs must include role-specific modules with competency assessments for each staff level involved in the systems. These should incorporate hands-on practice using the actual forms and procedures staff will use in their daily work.
Quality monitoring should include specific metrics for system performance: complaint resolution times, MDR reporting compliance, investigation thoroughness, and documentation completeness. Regular audits should evaluate both individual cases and overall system performance against these metrics.
Additional Considerations
Below are several additional critical considerations that LDT firms should understand when implementing these systems.
Practical Implementation
Documentation requirements deserve special attention beyond basic system design. Laboratories must establish specific procedures for maintaining the integrity and retrievability of all records. This includes implementing version control for all procedures and forms, establishing audit trails for any record modifications, and ensuring all documentation is readily accessible for FDA inspection.
- Given the interrelated nature of these systems, cross-referencing between complaint files, MDR reports, and correction/removal actions becomes crucial. Keep in mind that each system requires a robust change control process.
- When modifications are made to test processes, complaint-handling procedures, or reporting mechanisms, laboratories must assess the impact on all three systems. For instance, a change in test methodology might require updates to complaint evaluation criteria, MDR reporting thresholds, and correction/removal classification procedures.
Electronic Systems and Data Management
Labs need to have electronic systems to manage the documentation and reporting requirements that stretch across all three of these systems. Laboratories should consider whether their existing LIMS or quality management software can be adapted to handle these new requirements or if additional systems are needed.
- Any electronic systems used for these purposes must meet FDA's electronic records requirements. Custom worksheets and forms should be developed for each type of investigation and assessment. These should include specific fields for all required information and built-in logic to help guide decision-making. For example, MDR assessment forms should walk investigators through the criteria for reportability in a systematic, repeatable way.
Contractor and Vendor Management
Laboratories must establish clear procedures for handling complaints and events involving contracted services or purchased components. Errors occurring at contracted collection sites require different handling than internal errors. Clear procedures must specify how these situations are documented and when they trigger reporting requirements.
Business Continuity Considerations
Backup procedures must be established for all critical functions. This includes designating alternate personnel for key roles, establishing backup documentation systems in case of IT failures, and ensuring reporting capabilities are maintained even during system outages or other disruptions.
Quality Metrics and Performance Monitoring
Beyond basic compliance, laboratories should establish KPIs for each system:
Regular system reviews should examine these metrics to identify trends and improvement opportunities. This data can also help justify resource needs and system modifications over time.
Staff Roles and Responsibilities
Clear delineation of responsibilities is crucial. Laboratories should establish specific role definitions:
Regular system reviews should examine these metrics to identify trends and improvement opportunities. This data can also help justify resource needs and system modifications over time.
Communication
Clear communication channels must be established for each system, including:
Regular system reviews should examine these metrics to identify trends and improvement opportunities. This data can also help justify resource needs and system modifications over time.
Compliance Project Orchestration and Resourcing
The scope of Stage 1 compliance encompasses three interconnected systems that must work seamlessly together while maintaining distinct regulatory requirements. This demands not only technical expertise in regulatory compliance but also a deep understanding of laboratory operations and existing quality systems.
The path to compliance begins with establishing the foundational quality system elements that support all three required systems — MDR, corrections and removals, and complaint handling. Laboratories should map out dependencies between different implementation activities, identifying which elements must be completed before others can begin. For example, the complaint handling system must be operational before MDR procedures can be fully implemented, as complaints often trigger MDR evaluations. This critical path analysis helps laboratories avoid bottlenecks and ensure efficient resource utilization.
Working backward from the May 6, 2025 compliance deadline, laboratories should establish clear milestones that allow adequate time for system refinement and staff training.
Each milestone should include specific success criteria and deliverables. Importantly, laboratories should build in buffer time between major milestones to accommodate unexpected challenges and allow for system optimization based on early implementation experience.
Most laboratories will find their current staff lack specific experience with FDA reporting requirements, while external consultants may need time to understand laboratory-specific workflows and constraints. Therefore, a successful implementation requires thoughtful resource allocation and clear delineation of roles between internal staff and external partners.
Resource allocation must align with the intensity of different implementation phases. The initial documentation development phase typically requires the heaviest investment in consulting support and internal staff time. As implementation progresses, resource needs shift toward training and system validation activities. Laboratories should plan for these changing resource requirements, ensuring adequate staffing and expertise are available at each phase. This includes identifying when specific subject matter experts need to be engaged and planning for potential resource constraints during high-intensity periods.
Perhaps the most challenging aspect of timeline management is balancing compliance implementation with ongoing laboratory operations. Successful laboratories typically adopt a staged implementation approach, rolling out new systems in controlled phases to minimize operational disruption. This might involve piloting new procedures in specific departments before full implementation or implementing basic system elements before adding more complex components.
Project leaders should work closely with operational managers to identify critical operational periods and adjust implementation timelines accordingly. Additionally, laboratories should establish clear criteria for when implementation activities take precedence over routine operations and when they need to be temporarily scaled back to accommodate operational demands.
Below is a recommended step-by-step strategy for orchestrating a Stage 1 compliance project before the May, 2025 deadline.
Immediate Action: Secure Regulatory Consulting Support
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Phase 1: Initial Assessment and Organization
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Phase 2: Development of Procedures
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Phase 3: Testing and Implementation
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Consultant Skillset Requirements for Stage 1 LDT Compliance
The transition to FDA oversight requires consultants with specific expertise in three core areas: regulatory knowledge, quality systems implementation, and laboratory operations. The primary consultant should bring deep experience with the FDA's medical device reporting requirements and practical knowledge of implementing these systems in real-world settings.
Regulatory expertise must cover MDR requirements (21 CFR Part 803), corrections and removals (Part 806), and complaint handling (Part 820.198). The consultant needs hands-on experience with FDA's Electronic Submissions Gateway, Form 3500A submissions, and understanding of how these requirements interact with existing CLIA regulations. They should also have experience guiding organizations through FDA inspections and regulatory correspondence.
Quality system development expertise is crucial for creating robust but practical documentation systems. This includes designing standard operating procedures, work instructions, forms, and tracking systems that satisfy FDA requirements while remaining usable in daily laboratory operations. The consultant must understand how to integrate new processes with existing laboratory workflows and develop effective training programs.
Given the scope of Stage 1 requirements, laboratories are engaging multiple consultants with complementary skills.
A typical consulting team might include:
- A lead regulatory consultant focusing on MDR systems and FDA requirements
- A quality systems specialist handling documentation and process development
- An IT consultant supporting electronic submission systems implementation
- Laboratory operations specialists helping adapt systems to the LDT environment
The consulting team must excel at knowledge transfer, building internal capabilities that allow the laboratory to eventually operate these systems independently. Strong communication skills and experience managing similar implementations are essential, as consultants must work effectively with laboratory staff at all levels while navigating organizational change.
When selecting consultants, laboratories should prioritize demonstrated experience with similar implementations and understanding of both FDA requirements and laboratory operations. The right consulting team provides technical expertise and practical guidance for building sustainable compliance systems.
Getting Started: Your First Steps Toward Stage 1 Compliance
The path to Stage 1 compliance begins with three immediate actions that every laboratory should take upon finishing this guide.
- First, conduct a preliminary inventory of your LDT menu, identifying which tests qualify as LDTs under the FDA's definition and whether any might fall under partial exemption categories. This inventory should include basic information about test volumes, complexity, and current quality control measures. This initial assessment provides the foundation for all subsequent planning and helps determine the scope of your compliance project.
- Second, evaluate your current quality management leadership and identify who will own the Stage 1 compliance project. This individual should be a senior laboratory director or quality manager with both the authority to drive organizational change and the bandwidth to oversee a major regulatory implementation. If no current staff member fits this profile, begin planning for additional hiring or leadership restructuring.
- Third, initiate preliminary discussions with potential consulting partners. Schedule exploratory conversations with a firm who can help you access the professionals you need to understand their approach to Stage 1 implementation, assess their relevant experience with both FDA requirements and laboratory operations, and begin developing a rough budget framework for the project. Contact us today to start the conversation.
A Few Common Pitfalls to Avoid
The transition to FDA oversight presents several common challenges that laboratories should anticipate and plan to address.
How The FDA Group Can Guide You to Compliance
As a leader in FDA regulatory consulting, The FDA Group offers comprehensive support for laboratories navigating the complexities of LDT regulation. Our experienced team brings deep expertise in both FDA compliance and laboratory operations, providing end-to-end guidance through every aspect of Stage 1 implementation and beyond.
We understand that most laboratories are encountering FDA oversight for the first time and have very limited resources and understanding of the road ahead. We've structured our services to ensure a smooth, efficient transition to compliance.
Our comprehensive compliance support services include, but are not limited to:
1. Initial assessment and strategic planning
- Comprehensive gap analysis of current systems against FDA requirements
- LDT portfolio review and exemption assessment
- Development of detailed implementation roadmaps
- Resource planning
2. System development
- Design and implementation of MDR systems
- Creation of corrections and removals procedures
- Development of comprehensive complaint handling systems
- Integration with existing CLIA quality systems
- Documentation system development and optimization
3. Operational implementation
- Staff training program development and delivery
- Process validation and verification
- Mock FDA inspections and audit preparation
4. Project management and resourcing
- Implementation timeline development and management
- Resoucing planning and consultant identification
- Ongoing project management
The FDA Group offers flexible engagement models to meet your specific needs, from focused consulting on particular aspects of compliance to comprehensive program management. Our consultants can work on-site or remotely, scaling their involvement based on your internal capabilities and resource constraints.
Here are just a few of the reasons laboratories are partnering with us for compliance support:
- Deep expertise in both FDA regulations and laboratory operations
- Proven track record of successful regulatory implementations
- Comprehensive understanding of the unique challenges facing clinical laboratories
- Practical, efficiency-focused approach to compliance
- Strong relationships with regulatory authorities
- Ability to leverage best practices from across the industry
We believe in building true partnerships with our clients, working alongside your team to build sustainable compliance systems that enhance rather than hinder laboratory operations. Our consultants focus not just on meeting regulatory requirements but on optimizing processes to improve efficiency and quality while maintaining compliance.
Fill out and submit the form below to ensure you’re prepared by the Stage 1 deadline—on time and on budget.