I have to say I disagree with this interpretation. The commentary in the 7/11/2011 checklists indicates that regulations apply to "A laboratory must evaluate and document the competency of all testing personnel for each test system. A TEST SYSTEM is the process that includes pre-analytic, analytic, and post-analytic steps used to produce a test result or set of results." To me this includes both histology and pathology office staff.
This is the opinion on myself and our compliance person. Hazel can you tell us where to find the CAP quote. Thanks, Donna Willis, HT/HTL (ASCP) Histology Lab Manager Baylor University Medical Center-Dallas ph. 214-820-2465 office ph. 214-725-6184 mobile donna.wil...@baylorhealth.edu -----Original Message----- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Horn, Hazel V Sent: Thursday, May 17, 2012 7:26 AM To: 'Courtney Pierce' Cc: histonet@lists.utsouthwestern.edu Subject: [Histonet] RE: CAP vs. CLIA CAP does not consider us testing personnel. How they come by this is a mystery to me. In a recent memo from CAP it describes this: " Why does CAP require the completion of the "Laboratory Personnel Evaluation Roster" form and when was this process implemented? As part of CAP's deemed status with CMS as an accrediting organization, CMS required CAP to implement a more stringent process to document that accredited laboratories have appropriately qualified personnel and adequate documentation of personnel qualifications. The Laboratory Personnel Evaluation Roster form requires laboratories to confirm that personnel files contain the information necessary for laboratories to be in compliance with the CLIA personnel qualification regulations and CAP Checklist requirements prior to the inspection. It is also used by the inspection team to assist in the auditing of the records during the inspection to confirm compliance with the Checklist requirements. The process of completing the personnel form took effect in August 2009." And goes on to say: "Do I need to list histologists on the Laboratory Personnel Evaluation Roster? Typical histologist duties (e.g., fixation, embedding, microtomy, staining and cover slipping) are not considered testing. Therefore, it is not necessary to list these personnel on the roster. However, if the histologist is performing any part of the macroscopic tissue examination which is considered high complexity testing, it is necessary to list those personnel on the roster. Such personnel must provide documentation at minimum of an associate's degree/transcripts or high school diploma or equivalent for individuals performing grossing at the same laboratory prior to September 1, 1997." Hazel Horn Supervisor of Histology/Autopsy/Transcription Anatomic Pathology Arkansas Children's Hospital 1 Children's Way | Slot 820| Little Rock, AR 72202 501.364.4240 direct | 501.364.1302 office | 501.364.1241 fax hor...@archildrens.org archildrens.org 100 YEARS YOUNG! JOIN THE PARTY AT ach100.org -----Original Message----- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Courtney Pierce Sent: Wednesday, May 16, 2012 2:27 PM To: histonet@lists.utsouthwestern.edu Subject: [Histonet] CAP vs. CLIA Can someone help me with the High Complexity Test with CAP vs. CLIA. Thanks Courtney Pierce IHC Specialist Quintiles Translational R&D - Oncology Innovation Navigating the new health 610 Oakmont Lane Westmont, IL 60559 Office: + 630-203-6234 courtney.pie...@quintiles.com clinical | commercial | consulting | capital ********************** IMPORTANT--PLEASE READ ************************ This electronic message, including its attachments, is COMPANY CONFIDENTIAL and may contain PROPRIETARY or LEGALLY PRIVILEGED information. 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