All procedures must be reviewed annually (and that means WITHIN 12 months, not just once a calender year) This may be done by the appropriate supervisor or pathologist, not necessarily the Director (Director must review all new or changed procedures) The review should confirm that the procedure in operation matches what really happens. The laboratory must have in place a mechanism that demonstrates that the users of those procedures are familiar with them (and without digging up the CAP standards, i rely on my memory that this must also be documented in some format on an annual basis). I believe we accomplish this with an annual signed statement from the employees confirming they are familiar with the procedures they use. Bill Tench Associate Dir. Laboratory Services Chief, Cytology Services Palomar Medical Center 555 E. Valley Parkway Escondido, California 92025 bill.te...@pph.org Voice: 760- 739-3037 Fax: 760-739-2604
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