[Histonet] CAP Question

[Mac Donald, Jennifer via Histonet]

Good morning, and Happy Friday Histonet!



Do any of you have a policy or response for CYP.07666, CAP's new unsatisfactory 
non-gyn cytology that you would be willing to share?  We do few cytology cases 
here, this just isn't much of an issue; we've never really had to think about 
it.  Please help!



CYP.07666

There are written Criteria for identification and reporting of unsatisfactory 
non-gynecologic specimens, as applicable.
NOTE: The cytopathology report must state the reason for an unsatisfactory 
specimen


Thanks,

Brian D. Cooper, HT (ASCP)CM | Histology Supervisor
Department of Pathology and Laboratory Medicine
Children's Hospital Los Angeles
4650 Sunset Blvd MS#43- Los Angeles, CA 90027
Ph: 323.361.3357
bcoo...@chla.usc.edu




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Re: [Histonet] CAP question ANP.12500

[Eileen Akemi Allison via Histonet]

We keep ours for one week after final report. There have been past issues as to 
tissues  submitted from our endoscopy center not matching up to our gross 
exams. Gastric tissue included with esophageal tissue, I account for every 
MINUTE fragment, so there were absolutely floaters from somewhere!. We account 
for everything when I gross the tissue!  I have a embedding log sheet which 
accounts for every piece submitted, as well as who embeds it, cuts, it, etc.. 
as well as any comments which just don’t match up to the gross.

Akemi Allison BS, HT/HTL (ASCP)
Pathology Manager
Monterey Bay GI Consultants Laboratory
23 Upper Ragsdale Drive, Suite 200
Monterey, CA 93940
W: Email: aalli...@montereygi.com 
H: Email: akemiat3...@gmail.com 
Tele: (831) 375-3577 X117
Cell: (408) 335-9994

> On Sep 15, 2017, at 8:46 AM, Vickroy, James via Histonet 
>  wrote:
> 
> Wondered if something has changed on the question pertaining to retention.   
> We only do biopsies and keep the containers they come in for two days.   We 
> have done this forever.   Going through the new checklist I notice under wet 
> tissue it has (stock bottle).   Before I interpret this incorrectly, a stock 
> bottle to me meant left over fixed tissue not taken for sections.  Last week 
> I got an email saying this other institution was keeping the empty containers 
> for two weeks after final report.
> 
> Obviously, it is clear if we have left over tissue we hold it for the 
> specified time period but does this also mean we should be holding the empty 
> biopsy container for two weeks plus also?
> 
> I hope I am overthinking this since we don't have room for them.
> 
> Your thoughts?
> 
> Jim
> 
> Jim Vickroy
> Histology Manager
> Springfield Clinic, Main Campus, East Building
> 1025 South 6th Street
> Springfield, Illinois  62703
> Office:  217-528-7541, Ext. 15121
> Email:  jvick...@springfieldclinic.com
> 
> 
> 
> This electronic message contains information from Springfield Clinic, LLP 
> that may be confidential, privileged, and/or sensitive. This information is 
> intended for the use of the individual(s) or entity(ies) named above. If you 
> are not the intended recipient, be aware that disclosure, copying, 
> distribution, or action taken on the contents of this information is strictly 
> prohibited. If you have received this electronic message in error, please 
> notify the sender immediately, by electronic mail, so that arrangements may 
> be made for the retrieval of this electronic message. Thank you.
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[Histonet] CAP question ANP.12500

[Vickroy, James via Histonet]

Wondered if something has changed on the question pertaining to retention.   We 
only do biopsies and keep the containers they come in for two days.   We have 
done this forever.   Going through the new checklist I notice under wet tissue 
it has (stock bottle).   Before I interpret this incorrectly, a stock bottle to 
me meant left over fixed tissue not taken for sections.  Last week I got an 
email saying this other institution was keeping the empty containers for two 
weeks after final report.

Obviously, it is clear if we have left over tissue we hold it for the specified 
time period but does this also mean we should be holding the empty biopsy 
container for two weeks plus also?

I hope I am overthinking this since we don't have room for them.

Your thoughts?

Jim

Jim Vickroy
Histology Manager
Springfield Clinic, Main Campus, East Building
1025 South 6th Street
Springfield, Illinois  62703
Office:  217-528-7541, Ext. 15121
Email:  jvick...@springfieldclinic.com



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[Histonet] CAP Question

[Paula Sicurello]

Good Morning Netters,

How many antibodies are y'all testing to meet the CAP guideline
(COM.04250) that requires comparison testing of equipment performing the
same test (autostainers, for instance) twice a year?

I read it as requiring all antibodies are tested on all platforms, but that
seems a bit much.

Enquiring minds want to know.

Thanks a bunch!

Paula




Paula Sicurello, HTL (ASCP)CM

Histotechnology Specialist

UCSD Medical Center

200 Arbor Drive

San Diego, CA 92103

(P): 619-543-2872



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Re: [Histonet] CAP Question

[Michael Ann Jones]

It does seem like a bit much, but that¹s what we did
All antibodies, we ran, exact same lot # ran 3 on one machine and 3 on
another.

Michael Ann
Michael Ann Jones, HT (ASCP)
Histology Manager
Metropath
7444 W. Alaska Dr. #250
Lakewood, CO 80226
303.634.2511
mjo...@metropath.com






On 6/29/15, 11:33 AM, Paula Sicurello pat...@gmail.com wrote:

Good Morning Netters,

How many antibodies are y'all testing to meet the CAP guideline
(COM.04250) that requires comparison testing of equipment performing the
same test (autostainers, for instance) twice a year?

I read it as requiring all antibodies are tested on all platforms, but
that
seems a bit much.

Enquiring minds want to know.

Thanks a bunch!

Paula




Paula Sicurello, HTL (ASCP)CM

Histotechnology Specialist

UCSD Medical Center

200 Arbor Drive

San Diego, CA 92103

(P): 619-543-2872



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[Histonet] CAP Question CYP.04300 Daily QC

[Piche, Jessica]

Hi Everyone,

I am asking a question for our Cytology department about  CYP.04300 on the CAP 
checklist, in regards to daily QC.  It states the technical quality of the 
preparations should be checked daily and includes checking all stains for 
predicted staining characteristics each day of use. This check should include 
preparations performed in the lab such as cytospins, cell blocks, and liquid 
based automated preparations.

Is the question asking to document evidence of the technical quality of the 
stain or the technical quality in the preparation of the slide, ie smear, 
cytospin, etc? Or does it want both? Our cytology department uses several 
different protocols  and with several different slide preparations so they are 
wondering if they are supposed to run a control every day for every single type 
of slide prep or just every stain that is used?

We would be interested in knowing what everyone else does.

Thank you and have a great day!

Jessica Piche,HT(ASCP)
Waterbury Hospital



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[Histonet] CAP question ANP.22978 - Her2 assay validation

[Martha Ward-Pathology]

Hello all,

I have been reading through the most recent revisions and want to see how 
others are handling this question.   The explanation states that it is for new 
and existing assays and that if your validation does not meet current standards 
that you must supplement and bring it into compliance.  Furthermore if you do 
not have any documentation from the initial validation the assay must be fully 
revalidated and documented.

Our lab has been performing the Herceptest from Dako (FDA approved) since 
before 2008 and participating in the HER2 proficiency testing since it was 
first offered.   We have our statistical results comparing our IHC patient 
results to FISH Her2 results since 2008 and we have always done well on our CAP 
proficiency testing (95%-100%).We do inter-pathologist result comparisons, 
using know CAP slides and have 95% to 100% agreements.   

What I do not have however is the original results of the slides that were 
stained to set up the original assay.   Under these circumstances will we need 
to completely revalidate the assay, using the mandated 20+/20- cases, or can we 
simply do a retroactive formal review and write up of our past performances on 
our proficiency testing challenges?

Thanks in advance for your help with this!

 
Martha Ward, MT (ASCP) QIHC
Manager
 
Molecular Diagnostics Lab
Medical Center Boulevard  \  Winston-Salem, NC 27157


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[Histonet] CAP Question, New Reagent Lot Confirmation of Acceptability

[Laurie Colbert]

The above checklist item, ANP.22760, states The performance of new lots of 
antibody and detection system reagents is compared with old lots before or 
concurrently with being placed into service.  Neither the question, the note 
below it, nor the evidence of compliance states that a pathologist has to 
perform the comparison.  What are other labs doing?  Are the histotechs signing 
off on new lots?

Laurie Colbert, HT (ASCP)
Histology Supervisor
PATH MD
8158 Beverly Blvd.
Los Angeles, CA  90048
(323) 648-3214 direct
(424) 245-7284 main lab

The information contained in this transmission may contain privileged and 
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strictly prohibited. If you are not the intended recipient, please contact the 
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[Histonet] CAP question

[Madeline Gi]

I have a question which was asked before but I don't remember the answer, how 
many CEU's are required by CAP for a histologist in New York City. Thanks in 
advance 

Madeline Rotger Milanese H.T. BSHCS
500 New Hempstead Rd.
New City N.Y. 10965
845-362-3200 Ext 129
madelin...@yahoo.com
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Re: [Histonet] CAP question

[Lee Peggy Wenk]

CAP does not put any number as to how much CE is required for working techs. 
Just that there is a CE program (54200), and that there is a record of CE in 
the personnel records (54400, #6).


GEN.54200 Continuing Education Phase I
There is a functional continuing clinical laboratory education program 
adequate to meet the needs of all personnel.

Evidence of Compliance: Written policy for continuing laboratory education

GEN.54400 Personnel Records Phase II
Personnel files are maintained on all current technical personnel and 
personnel records include all of the following items.

1. Summary of training and experience
2. Copy of academic degree or transcript
3. License, if required by state
4. Certification, if required by state or employer
5. Description of current duties and responsibilities as specified by the 
laboratory director: a) Procedures the individual is authorized to perform, 
b) Whether supervision is required for specimen processing, test performance 
or result reporting, c) Whether supervisory or director review is required 
to report patient test results

6. Records of continuing education
7. Records of radiation exposure where applicable (such as with in vivo 
radiation testing), but not required for low exposure levels such as certain 
in-vitro testing

8. Work-related incident and/or accident records
9. Dates of employment

However, the CMP (Competency Maintenance programP of ASCP says, if you are a 
certified tech (certified on or after Jan. 1, 2004), you need 36 hours CE 
every 3 years, to maintain your certification.


http://ascp.org/PDF/BOC-PDFs/CMP/CMPBooklet.aspx

Peggy A. Wenk, HTL(ASCP)SLS
Beaumont Health System
Royal Oak, MI 48073

The opinions expressed are mine, and do not reflect my place of employment.

-Original Message- 
From: Madeline Gi

Sent: Tuesday, May 21, 2013 4:20 PM
To: Histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP question

I have a question which was asked before but I don't remember the answer, 
how many CEU's are required by CAP for a histologist in New York City. 
Thanks in advance


Madeline Rotger Milanese H.T. BSHCS
500 New Hempstead Rd.
New City N.Y. 10965
845-362-3200 Ext 129
madelin...@yahoo.com
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[Histonet] CAP Question

[Schaundra Walton]

I have a question regarding a new CAP checklist question
dealing with ER/PR validation.  The new question is ANP.22976 ER/PgR
Validation and states: 
  
“If the laboratory performs immunohistochemistry for
estrogen receptor (ER) and/or progesterone receptor (PgR) as a
prognostic/predictive marker on breast carcinoma, the laboratory has documented
appropriate validation for the assay(s).  
 Note: Initial test validation should include a
minimum of 40 cases (20 positive and 20 negative cases) for
FDA-approved/cleared tests; laboratories should consider using higher numbers
of test cases if a Laboratory Developed or Laboratory Modified Test is to be
validated.  Validation should be performed by comparing the laboratory’s
results with another assay that has been appropriately validated. 
Acceptable concordance levels are 90% for positive results and 95% for negative
results.  If significant changes are made to the testing methods (e.g.
antibody clones, antigen retrieval protocol or detection system) revalidation
is required. “ 
  
Our original validation was done in 2005 and was performed
with 20 cases.  Do we need to revalidate to be compliant with this
question?  Should we start from scratch or just do an additional 20 cases?  
 
Any feedback is appreciated.
 
Thanks! 
Schaundra Walton BS HTL(ASCP)
Histology Supervisor
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RE: [Histonet] CAP Question -ER/PR Validation

[Settembre, Dana]

You should pose that question to CAP via
acc...@cap.org

they answer quickly and when they do you can print out their answer and keep 
for when your inspectors come.

When I asked them that question, they said that it was usually at the 
discretion of the pathologist in charge.  But instead of taking my word for 
It, email them  and when you receive their response, print it.
Then follow their instructions.

Dana Settembre


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Schaundra Walton
Sent: Monday, April 16, 2012 11:34 AM
To: Histonet
Subject: [Histonet] CAP Question



I have a question regarding a new CAP checklist question
dealing with ER/PR validation.  The new question is ANP.22976 ER/PgR
Validation and states: 
  
If the laboratory performs immunohistochemistry for
estrogen receptor (ER) and/or progesterone receptor (PgR) as a
prognostic/predictive marker on breast carcinoma, the laboratory has documented
appropriate validation for the assay(s).  
 Note: Initial test validation should include a
minimum of 40 cases (20 positive and 20 negative cases) for
FDA-approved/cleared tests; laboratories should consider using higher numbers
of test cases if a Laboratory Developed or Laboratory Modified Test is to be
validated.  Validation should be performed by comparing the laboratory's
results with another assay that has been appropriately validated. 
Acceptable concordance levels are 90% for positive results and 95% for negative
results.  If significant changes are made to the testing methods (e.g.
antibody clones, antigen retrieval protocol or detection system) revalidation
is required.  
  
Our original validation was done in 2005 and was performed
with 20 cases.  Do we need to revalidate to be compliant with this
question?  Should we start from scratch or just do an additional 20 cases?  
 
Any feedback is appreciated.
 
Thanks! 
Schaundra Walton BS HTL(ASCP)
Histology Supervisor
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RE: [Histonet] CAP Question

[Morken, Timothy]

Shaundra,

The CAP requirements are for those who are starting ER/PR for the first time, 
or changing antibodies to a new clone. If you did the validation years ago 
before those recommendations came out and have a history of running it 
successfully then you do not have to re-validate the procedure.

If you change antibodies to new clones, then you would have to do the more 
extensive validation.

Tim Morken


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Schaundra Walton
Sent: Monday, April 16, 2012 8:34 AM
To: Histonet
Subject: [Histonet] CAP Question



I have a question regarding a new CAP checklist question dealing with ER/PR 
validation.  The new question is ANP.22976 ER/PgR Validation and states: 
  
“If the laboratory performs immunohistochemistry for estrogen receptor (ER) 
and/or progesterone receptor (PgR) as a prognostic/predictive marker on breast 
carcinoma, the laboratory has documented appropriate validation for the 
assay(s).  
 Note: Initial test validation should include a minimum of 40 cases (20 
positive and 20 negative cases) for FDA-approved/cleared tests; laboratories 
should consider using higher numbers of test cases if a Laboratory Developed or 
Laboratory Modified Test is to be validated.  Validation should be performed by 
comparing the laboratory’s results with another assay that has been 
appropriately validated. Acceptable concordance levels are 90% for positive 
results and 95% for negative results.  If significant changes are made to the 
testing methods (e.g.
antibody clones, antigen retrieval protocol or detection system) revalidation 
is required. “ 
  
Our original validation was done in 2005 and was performed with 20 cases.  Do 
we need to revalidate to be compliant with this question?  Should we start from 
scratch or just do an additional 20 cases?  
 
Any feedback is appreciated.
 
Thanks!
Schaundra Walton BS HTL(ASCP)
Histology Supervisor
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Re: [Histonet] CAP question ANP.22970

[Richard Cartun]

Here's an excellent reference -  Ross JS: Saving Lives with Accurate HER2 
Testing Am J Clin Pathol  2010;134:183-184.

I quote, A number of experts in the field have now agreed that a laboratory 
performing HER2 testing in the US patient population should have a HER2+ rate 
of approximately 16% with a range of 12% to 20%.

Richard

Richard W. Cartun, MS, PhD
Director, Histology  Immunopathology
Director, Biospecimen Collection Programs
Assistant Director, Anatomic Pathology
Hartford Hospital
80 Seymour Street
Hartford, CT  06102
(860) 545-1596 Office
(860) 545-2204 Fax


 Martha Ward mw...@wfubmc.edu 2/1/2011 12:57 PM 
We are having our inspection this spring and I am working to get all our 
procedures, etc. ready.  I am having trouble finding benchmark information for 
comparison for HER2 to comply with this question - ...the laboratory at least 
annually compares its patient results with published benchmarks,   We are 
using the Dako Herceptest.  I spoke with Dako tech services and they did not 
have any information.   What are other labs using for a benchmark.

Thanks in advance for all your help.

Martha Ward, MT (ASCP) QIHC
Assistant Manager
Molecular Diagnostics Lab
Dept. of Pathology
Wake Forest University Baptist Medical Center
Winston-Salem, NC 27157
336-716-2104

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[Histonet] CAP question for pediatric pathology labs

[Houston, Ronald]

CYP.00190

Phase I

N/A YES NO

For laboratories that perform non-gynecologic cytopathology, does the 
laboratory participate in a peer educational program in NON-GYNECOLOGIC 
cytopathology (e.g., CAP Interlaboratory Comparison Program in Non-Gynecologic 
Cytopathology NGC)?

How are labs responding to this request for a peer-educational program in 
non-gyn cytopath, as there is no such program for pediatric cytopathology, and, 
in the opinion of our pathologists, the CAP program is useless as far as it 
pertains to pediatrics?

We have had varying responses from inspectors which we have adopted and then 
the next inspector says this isn't good enough and you should be doing 
something else. There has been little to no direction from CAP.

Thanks

Ronnie Houston, MS HT(ASCP)QIHC
Anatomic Pathology Manager

ChildLab, a Division of Nationwide Children's Hospital

www.childlab.com


700 Children's Drive
Columbus, OH 43205
(P) 614-722-5450
(F) 614-722-2899
ronald.hous...@nationwidechildrens.orgmailto:ronald.hous...@nationwidechildrens.org
www.NationwideChildrens.orghttp://www.NationwideChildrens.org

One person with passion is better than forty people merely interested.
~ E.M. Forster



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RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - Email found in subject

[Kim . Donadio]

Do others document separately the original creation, training, competency, 
implementation of procedures/processes and then continual yearly training, 
competency and review of those processes? Are you using a Quality 
Management System? How about Electronic system to manage?

Yes, to all of those. We document original training and then all 
competencies are part of their yearly eval. We also have the QMS 
electronic policy/procedure Data base that sends each individual reminders 
when they need to read a update or sign off on the yearly requirement that 
they have read and understand the material. 




Kim Donadio 
Pathology Supervisor
Baptist Hospital
1000 W Moreno St.
Pensacola FL 32501
Phone (850) 469-7718
Fax (850) 434-4996



WILLIAM DESALVO wdesalvo@hotmail.com 
Sent by: histonet-boun...@lists.utsouthwestern.edu
12/23/2010 10:49 AM

To
rcaza...@schosp.org, histonet histonet@lists.utsouthwestern.edu
cc

Subject
RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - 
Email found in subject







Thanks, I am aware of Peggy's form. We have similar hard copy forms now, 
but we are moving to an electronic system. It will be much more manageable 
for 125 employees.
 
When you state in your form the employee is competent, do you have 
documentation to support that there was a competency evaluation? We only 
state the employee has read and understands. We have separate 
documentation for training and competency.
 
I love this type of discussion string. There are so many different 
processes out in Histoland.
 
Do others document separately the original creation, training, competency, 
implementation of procedures/processes and then continual yearly training, 
competency and review of those processes? Are you using a Quality 
Management System? How about Electronic system to manage?

William DeSalvo, B.S., HTL(ASCP)




 
 From: rcaza...@schosp.org
 To: wdesalvo@hotmail.com
 Date: Thu, 23 Dec 2010 10:17:48 -0600
 Subject: RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure 
manual - Email found in subject
 
 Hello histonetters,
 
 When I implement a new procedure in my lab, besides the routine yearly 
sign-off sheet that accompanies the procedure, there an additional sheet 
that states
 
  The following employees have reviewed this procedure and by signing 
below are acknowledging that they understand and are competent in 
performing the procedure:
 
 Below that statement is a box with signature and date lines for all the 
employees using this procedure to sign. This makes each employee 
responsible for reading and understanding the procedure. This I got from 
one of Peggy Wenk's workshops (Thanks Peggy!!). I can send a copy to 
anyone who'd like one, just contact me directly.
 
 
 Ruth Cazares, HT (ASCP)
 Histology Supervisor
 Department of Pathology
 Swedish Covenant Hospital
 Chicago, IL
 
 
 
 
 
 -Original Message-
 From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of WILLIAM 
DESALVO
 Sent: Thursday, December 23, 2010 7:27 AM
 To: bsulli...@shorememorial.org; Victor Tobias
 Cc: histonet; histonet-boun...@lists.utsouthwestern.edu
 Subject: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure 
manual - Email found in subject
 
 
 Beatrice,
 How do you show proof to CAP that your employees that use the procedures 
and perform the tasks described in the procedures have reviewed and 
understand the procedure when there is a new one during your cycle year 
and before it is implemented?
 
 CAP has changed the way they inspect and they are now looking for how 
whether the employees performing a task described in the procedure 
understands the procedure and is performing exactly as the procedure 
describes. They are not as concerned that the Supervisor and management 
knows about the procedures, they want to see how informed, trained and 
competent the bench employee is.
 
 William DeSalvo, B.S., HTL(ASCP)
 
 
 
 
 
  To: vic...@pathology.washington.edu
  From: bsulli...@shorememorial.org
  Date: Thu, 23 Dec 2010 07:53:22 -0500
  Subject: Re: [Histonet] CAP Question regarding procedure manual
  CC: Histonet@lists.utsouthwestern.edu; 
histonet-boun...@lists.utsouthwestern.edu
 
  Victor,
  To my knowledge all you need is proof that the staff reviewed the 
manuals.
  We accomplish this by a sign off sheet in the front of each manual we 
use.
  The Supervisor, or designee, needs to review and sign off on each 
procedure
  in each manual.
 
  Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
  AP Supervisor
  Shore Memorial Hospital
  609-653-3590
 
 
  Speak only well of people and you need never whisper
 
 
 
  Victor Tobias
  vic...@pathology
  .washington.edu To
  Sent by: Histonet
  histonet-bounces@ Histonet@lists.utsouthwestern.edu
  lists.utsouthwest cc
  ern.edu
  Subject
  [Histonet] CAP Question regarding
  12/22/2010 06:16 procedure manual
  PM

Re: [Histonet] CAP Question regarding procedure manual

[BSullivan]

Victor,
 To my knowledge all you need is proof that the staff reviewed the manuals.
We accomplish this by a sign off sheet in the front of each manual we use.
The Supervisor, or designee, needs to review and sign off on each procedure
in each manual.

Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
AP Supervisor
Shore Memorial Hospital
609-653-3590


Speak only well of people and you need never whisper


   
 Victor Tobias 
 vic...@pathology 
 .washington.edu   To 
 Sent by:  Histonet
 histonet-bounces@ Histonet@lists.utsouthwestern.edu 
 lists.utsouthwest  cc 
 ern.edu   
   Subject 
   [Histonet] CAP Question regarding   
 12/22/2010 06:16  procedure manual
 PM
   
   
   
   
   




Is there a requirement to have a signature of every staff member on a
procedure if they perform that procedure in a manual? Wouldn't one
signature on a cover page suffice that you have read and understand what
is in the manual?

Victor

--
Victor Tobias
Clinical Applications Analyst
University of Washington Medical Center
Dept of Pathology Room BB220
1959 NE Pacific
Seattle, WA 98195
vic...@pathology.washington.edu
206-598-2792
206-598-7659 Fax
=
Privileged, confidential or patient identifiable information may be
contained in this message. This information is meant only for the use
of the intended recipients. If you are not the intended recipient, or
if the message has been addressed to you in error, do not read,
disclose, reproduce, distribute, disseminate or otherwise use this
transmission. Instead, please notify the sender by reply e-mail, and
then destroy all copies of the message and any attachments.


___
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Histonet@lists.utsouthwestern.edu
http://lists.utsouthwestern.edu/mailman/listinfo/histonet



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RE: [Histonet] CAP Question regarding procedure manual

[WILLIAM DESALVO]

Beatrice,
How do you show proof to CAP that your employees that use the procedures and 
perform the tasks described in the procedures have reviewed and understand the 
procedure when there is a new one during your cycle year and before it is 
implemented?

CAP has changed the way they inspect and they are now looking for how whether 
the employees performing a task described in the procedure understands the 
procedure and is performing exactly as the procedure describes. They are not as 
concerned that the Supervisor and management knows about the procedures, they 
want to see how informed, trained and competent the bench employee is. 

William DeSalvo, B.S., HTL(ASCP)





 To: vic...@pathology.washington.edu
 From: bsulli...@shorememorial.org
 Date: Thu, 23 Dec 2010 07:53:22 -0500
 Subject: Re: [Histonet] CAP Question regarding procedure manual
 CC: Histonet@lists.utsouthwestern.edu; 
 histonet-boun...@lists.utsouthwestern.edu
 
 Victor,
  To my knowledge all you need is proof that the staff reviewed the manuals.
 We accomplish this by a sign off sheet in the front of each manual we use.
 The Supervisor, or designee, needs to review and sign off on each procedure
 in each manual.
 
 Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
 AP Supervisor
 Shore Memorial Hospital
 609-653-3590
 
 
 Speak only well of people and you need never whisper
 
 

  Victor Tobias 
  vic...@pathology 
  .washington.edu   To 
  Sent by:  Histonet
  histonet-bounces@ Histonet@lists.utsouthwestern.edu 
  lists.utsouthwest  cc 
  ern.edu   
Subject 
[Histonet] CAP Question regarding   
  12/22/2010 06:16  procedure manual
  PM





 
 
 
 
 Is there a requirement to have a signature of every staff member on a
 procedure if they perform that procedure in a manual? Wouldn't one
 signature on a cover page suffice that you have read and understand what
 is in the manual?
 
 Victor
 
 --
 Victor Tobias
 Clinical Applications Analyst
 University of Washington Medical Center
 Dept of Pathology Room BB220
 1959 NE Pacific
 Seattle, WA 98195
 vic...@pathology.washington.edu
 206-598-2792
 206-598-7659 Fax
 =
 Privileged, confidential or patient identifiable information may be
 contained in this message. This information is meant only for the use
 of the intended recipients. If you are not the intended recipient, or
 if the message has been addressed to you in error, do not read,
 disclose, reproduce, distribute, disseminate or otherwise use this
 transmission. Instead, please notify the sender by reply e-mail, and
 then destroy all copies of the message and any attachments.
 
 
 ___
 Histonet mailing list
 Histonet@lists.utsouthwestern.edu
 http://lists.utsouthwestern.edu/mailman/listinfo/histonet
 
 
 
 ___
 Histonet mailing list
 Histonet@lists.utsouthwestern.edu
 http://lists.utsouthwestern.edu/mailman/listinfo/histonet
  
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RE: [Histonet] CAP Question regarding procedure manual

[BSullivan]

When there is a change or new procedure made part of the existing manual it
is noted on a separate sheet designated for this. After this new or changed
procedure is signed off by the Medical Director it is given to the rest of
the department to read. This is initialed by each person on that sheet.
These sheets are within the manuals.

Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
AP Supervisor
Shore Memorial Hospital
609-653-3590


Speak only well of people and you need never whisper


   
 WILLIAM DESALVO   
 wdesalvo@hot 
 mail.com  To 
   bsulli...@shorememorial.org,  
 12/23/2010 08:26  Victor Tobias   
 AMvic...@pathology.washington.edu   
cc 
   histonet
   histonet@lists.utsouthwestern.edu 
   ,   
   histonet-boun...@lists.utsouthwest 
   ern.edu
   Subject 
   RE: [Histonet] CAP Question 
   regarding procedure manual  
   
   
   
   
   
   




Beatrice,
How do you show proof to CAP that your employees that use the procedures
and perform the tasks described in the procedures have reviewed and
understand the procedure when there is a new one during your cycle year and
before it is implemented?

CAP has changed the way they inspect and they are now looking for how
whether the employees performing a task described in the procedure
understands the procedure and is performing exactly as the procedure
describes. They are not as concerned that the Supervisor and management
knows about the procedures, they want to see how informed, trained and
competent the bench employee is.

William DeSalvo, B.S., HTL(ASCP)





 To: vic...@pathology.washington.edu
 From: bsulli...@shorememorial.org
 Date: Thu, 23 Dec 2010 07:53:22 -0500
 Subject: Re: [Histonet] CAP Question regarding procedure manual
 CC: Histonet@lists.utsouthwestern.edu;
histonet-boun...@lists.utsouthwestern.edu

 Victor,
 To my knowledge all you need is proof that the staff reviewed the
manuals.
 We accomplish this by a sign off sheet in the front of each manual we
use.
 The Supervisor, or designee, needs to review and sign off on each
procedure
 in each manual.

 Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
 AP Supervisor
 Shore Memorial Hospital
 609-653-3590


 Speak only well of people and you need never whisper



 Victor Tobias
 vic...@pathology
 .washington.edu To
 Sent by: Histonet
 histonet-bounces@ Histonet@lists.utsouthwestern.edu
 lists.utsouthwest cc
 ern.edu
 Subject
 [Histonet] CAP Question regarding
 12/22/2010 06:16 procedure manual
 PM









 Is there a requirement to have a signature of every staff member on a
 procedure if they perform that procedure in a manual? Wouldn't one
 signature on a cover page suffice that you have read and understand what
 is in the manual?

 Victor

 --
 Victor Tobias
 Clinical Applications Analyst
 University of Washington Medical Center
 Dept of Pathology Room BB220
 1959 NE Pacific
 Seattle, WA 98195
 vic...@pathology.washington.edu
 206-598-2792
 206-598-7659 Fax
 =
 Privileged, confidential or patient identifiable information may be
 contained in this message. This information is meant only for the use
 of the intended recipients. If you are not the intended recipient, or
 if the message has been addressed to you in error, do not read,
 disclose, reproduce, distribute, disseminate or otherwise use this
 transmission. Instead, please notify the sender by reply e-mail, and
 then destroy all copies of the message and any attachments.


 ___
 Histonet mailing list
 Histonet@lists.utsouthwestern.edu
 http://lists.utsouthwestern.edu/mailman/listinfo/histonet



 ___
 Histonet

RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - Email found in subject

[WILLIAM DESALVO]

Thanks, I am aware of Peggy's form. We have similar hard copy forms now, but we 
are moving to an electronic system. It will be much more manageable for 125 
employees.
 
When you state in your form the employee is competent, do you have 
documentation to support that there was a competency evaluation? We only state 
the employee has read and understands. We have separate documentation for 
training and competency.
 
I love this type of discussion string. There are so many different processes 
out in Histoland.
 
Do others document separately the original creation, training, competency, 
implementation of procedures/processes and then continual yearly training, 
competency and review of those processes? Are you using a Quality Management 
System? How about Electronic system to manage?

William DeSalvo, B.S., HTL(ASCP)




 
 From: rcaza...@schosp.org
 To: wdesalvo@hotmail.com
 Date: Thu, 23 Dec 2010 10:17:48 -0600
 Subject: RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure 
 manual - Email found in subject
 
 Hello histonetters,
 
 When I implement a new procedure in my lab, besides the routine yearly 
 sign-off sheet that accompanies the procedure, there an additional sheet that 
 states
 
  The following employees have reviewed this procedure and by signing below 
 are acknowledging that they understand and are competent in performing the 
 procedure:
 
 Below that statement is a box with signature and date lines for all the 
 employees using this procedure to sign. This makes each employee responsible 
 for reading and understanding the procedure. This I got from one of Peggy 
 Wenk's workshops (Thanks Peggy!!). I can send a copy to anyone who'd like 
 one, just contact me directly.
 
 
 Ruth Cazares, HT (ASCP)
 Histology Supervisor
 Department of Pathology
 Swedish Covenant Hospital
 Chicago, IL
 
 
 
 
 
 -Original Message-
 From: histonet-boun...@lists.utsouthwestern.edu 
 [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of WILLIAM 
 DESALVO
 Sent: Thursday, December 23, 2010 7:27 AM
 To: bsulli...@shorememorial.org; Victor Tobias
 Cc: histonet; histonet-boun...@lists.utsouthwestern.edu
 Subject: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - 
 Email found in subject
 
 
 Beatrice,
 How do you show proof to CAP that your employees that use the procedures and 
 perform the tasks described in the procedures have reviewed and understand 
 the procedure when there is a new one during your cycle year and before it is 
 implemented?
 
 CAP has changed the way they inspect and they are now looking for how whether 
 the employees performing a task described in the procedure understands the 
 procedure and is performing exactly as the procedure describes. They are not 
 as concerned that the Supervisor and management knows about the procedures, 
 they want to see how informed, trained and competent the bench employee is.
 
 William DeSalvo, B.S., HTL(ASCP)
 
 
 
 
 
  To: vic...@pathology.washington.edu
  From: bsulli...@shorememorial.org
  Date: Thu, 23 Dec 2010 07:53:22 -0500
  Subject: Re: [Histonet] CAP Question regarding procedure manual
  CC: Histonet@lists.utsouthwestern.edu; 
  histonet-boun...@lists.utsouthwestern.edu
 
  Victor,
  To my knowledge all you need is proof that the staff reviewed the manuals.
  We accomplish this by a sign off sheet in the front of each manual we use.
  The Supervisor, or designee, needs to review and sign off on each procedure
  in each manual.
 
  Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
  AP Supervisor
  Shore Memorial Hospital
  609-653-3590
 
 
  Speak only well of people and you need never whisper
 
 
 
  Victor Tobias
  vic...@pathology
  .washington.edu To
  Sent by: Histonet
  histonet-bounces@ Histonet@lists.utsouthwestern.edu
  lists.utsouthwest cc
  ern.edu
  Subject
  [Histonet] CAP Question regarding
  12/22/2010 06:16 procedure manual
  PM
 
 
 
 
 
 
 
 
 
  Is there a requirement to have a signature of every staff member on a
  procedure if they perform that procedure in a manual? Wouldn't one
  signature on a cover page suffice that you have read and understand what
  is in the manual?
 
  Victor
 
  --
  Victor Tobias
  Clinical Applications Analyst
  University of Washington Medical Center
  Dept of Pathology Room BB220
  1959 NE Pacific
  Seattle, WA 98195
  vic...@pathology.washington.edu
  206-598-2792
  206-598-7659 Fax
  =
  Privileged, confidential or patient identifiable information may be
  contained in this message. This information is meant only for the use
  of the intended recipients. If you are not the intended recipient, or
  if the message has been addressed to you in error, do not read,
  disclose, reproduce, distribute, disseminate or otherwise use this
  transmission. Instead, please notify the sender by reply e-mail, and
  then destroy all copies of the message and any attachments

RE: [SPAM-HC] - RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - Email found in subject - Email found in subject

[Cazares, Ruth]

Hi William,

Our competency evaluation is done once a year as part of the employee's annual 
evaluation.  I don't actually have each employee perform the procedure as part 
of the documentation, although. h, maybe an in-service to 
discuss the new procedure with all employees?

I agree with you about discussing things on Histonet, I have found it to be a 
lifesaver on more than one occasion (OK, so maybe that's a little dramatic, but 
you get the point) :)


Ruth Cazares, HT (ASCP)
Histology Supervisor
Department of Pathology
Swedish Covenant Hospital
Chicago, IL





From: WILLIAM DESALVO [mailto:wdesalvo@hotmail.com]
Sent: Thursday, December 23, 2010 10:50 AM
To: Cazares, Ruth; histonet
Subject: [SPAM-HC] - RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding 
procedure manual - Email found in subject - Email found in subject

Thanks, I am aware of Peggy's form. We have similar hard copy forms now, but we 
are moving to an electronic system. It will be much more manageable for 125 
employees.

When you state in your form the employee is competent, do you have 
documentation to support that there was a competency evaluation? We only state 
the employee has read and understands. We have separate documentation for 
training and competency.

I love this type of discussion string. There are so many different processes 
out in Histoland.

Do others document separately the original creation, training, competency, 
implementation of procedures/processes and then continual yearly training, 
competency and review of those processes? Are you using a Quality Management 
System? How about Electronic system to manage?

William DeSalvo, B.S., HTL(ASCP)





 From: rcaza...@schosp.org
 To: wdesalvo@hotmail.com
 Date: Thu, 23 Dec 2010 10:17:48 -0600
 Subject: RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure 
 manual - Email found in subject

 Hello histonetters,

 When I implement a new procedure in my lab, besides the routine yearly 
 sign-off sheet that accompanies the procedure, there an additional sheet that 
 states

  The following employees have reviewed this procedure and by signing below 
 are acknowledging that they understand and are competent in performing the 
 procedure:

 Below that statement is a box with signature and date lines for all the 
 employees using this procedure to sign. This makes each employee responsible 
 for reading and understanding the procedure. This I got from one of Peggy 
 Wenk's workshops (Thanks Peggy!!). I can send a copy to anyone who'd like 
 one, just contact me directly.


 Ruth Cazares, HT (ASCP)
 Histology Supervisor
 Department of Pathology
 Swedish Covenant Hospital
 Chicago, IL





 -Original Message-
 From: histonet-boun...@lists.utsouthwestern.edu 
 [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of WILLIAM 
 DESALVO
 Sent: Thursday, December 23, 2010 7:27 AM
 To: bsulli...@shorememorial.org; Victor Tobias
 Cc: histonet; histonet-boun...@lists.utsouthwestern.edu
 Subject: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - 
 Email found in subject


 Beatrice,
 How do you show proof to CAP that your employees that use the procedures and 
 perform the tasks described in the procedures have reviewed and understand 
 the procedure when there is a new one during your cycle year and before it is 
 implemented?

 CAP has changed the way they inspect and they are now looking for how whether 
 the employees performing a task described in the procedure understands the 
 procedure and is performing exactly as the procedure describes. They are not 
 as concerned that the Supervisor and management knows about the procedures, 
 they want to see how informed, trained and competent the bench employee is.

 William DeSalvo, B.S., HTL(ASCP)





  To: vic...@pathology.washington.edu
  From: bsulli...@shorememorial.org
  Date: Thu, 23 Dec 2010 07:53:22 -0500
  Subject: Re: [Histonet] CAP Question regarding procedure manual
  CC: Histonet@lists.utsouthwestern.edu; 
  histonet-boun...@lists.utsouthwestern.edu
 
  Victor,
  To my knowledge all you need is proof that the staff reviewed the manuals.
  We accomplish this by a sign off sheet in the front of each manual we use.
  The Supervisor, or designee, needs to review and sign off on each procedure
  in each manual.
 
  Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
  AP Supervisor
  Shore Memorial Hospital
  609-653-3590
 
 
  Speak only well of people and you need never whisper
 
 
 
  Victor Tobias
  vic...@pathology
  .washington.edu To
  Sent by: Histonet
  histonet-bounces@ Histonet@lists.utsouthwestern.edu
  lists.utsouthwest cc
  ern.edu
  Subject
  [Histonet] CAP Question regarding
  12/22/2010 06:16 procedure manual
  PM
 
 
 
 
 
 
 
 
 
  Is there a requirement to have a signature of every staff member on a
  procedure if they perform that procedure in a manual? Wouldn't one
  signature on a cover page suffice that you have read

[Histonet] CAP Question regarding procedure manual

[Victor Tobias]

Is there a requirement to have a signature of every staff member on a 
procedure if they perform that procedure in a manual? Wouldn't one 
signature on a cover page suffice that you have read and understand what 
is in the manual?


Victor

--
Victor Tobias
Clinical Applications Analyst
University of Washington Medical Center
Dept of Pathology Room BB220
1959 NE Pacific
Seattle, WA 98195
vic...@pathology.washington.edu
206-598-2792
206-598-7659 Fax
=
Privileged, confidential or patient identifiable information may be
contained in this message. This information is meant only for the use
of the intended recipients. If you are not the intended recipient, or
if the message has been addressed to you in error, do not read,
disclose, reproduce, distribute, disseminate or otherwise use this
transmission. Instead, please notify the sender by reply e-mail, and
then destroy all copies of the message and any attachments.


___
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RE: [Histonet] CAP Question regarding procedure manual

[Weems, Joyce]

Please tell me that is good enough! We do that here - for each manual.  

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Victor Tobias
Sent: Wednesday, December 22, 2010 18:17
To: Histonet
Subject: [Histonet] CAP Question regarding procedure manual

Is there a requirement to have a signature of every staff member on a procedure 
if they perform that procedure in a manual? Wouldn't one signature on a cover 
page suffice that you have read and understand what is in the manual?

Victor

--
Victor Tobias
Clinical Applications Analyst
University of Washington Medical Center
Dept of Pathology Room BB220
1959 NE Pacific
Seattle, WA 98195
vic...@pathology.washington.edu
206-598-2792
206-598-7659 Fax
=
Privileged, confidential or patient identifiable information may be contained 
in this message. This information is meant only for the use of the intended 
recipients. If you are not the intended recipient, or if the message has been 
addressed to you in error, do not read, disclose, reproduce, distribute, 
disseminate or otherwise use this transmission. Instead, please notify the 
sender by reply e-mail, and then destroy all copies of the message and any 
attachments.


___
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This e-mail, including any attachments is the 
property of Catholic Health East and is intended 
for the sole use of the intended recipient(s).  
It may contain information that is privileged and 
confidential.  Any unauthorized review, use,
disclosure, or distribution is prohibited. If you are 
not the intended recipient, please delete this message, and 
reply to the sender regarding the error in a separate email.


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RE: [Histonet] CAP Question regarding procedure manual

[WILLIAM DESALVO]

You will need a signature for the manual and for each procedure that is 
implemented or amended during your cycle year. If your manual is very stable, a 
yearly signature page for the entire manual may suffice, but the inspector will 
note the date everyone signed the manual review page and then go through the 
manual to see if there are any implementation dates or procedure change dates 
after the manual review date. Each occurrence found one can be a deficiency.

In my lab, it is not uncommon for new procedures to be written and implemented 
or existing procedures implemented during a cycle year and all these events 
require a signature by System Medical Director, Site Medical Director, Site Lab 
Director, System Technical Specialist (responsible for physically writing) and 
all employees affected. You must prove to CAP that all personnel know where the 
procedure manual is located, that they have reviewed the manual as a whole and 
that they have reviewed all additions implemented. We have employees sign each 
technical alert, procedure update/change and new procedures, along with a once 
a year review of all manuals.

This type of signature trail is part of and right in line with quality 
management and document control. This process alone can be a daunting task and 
requires a lot or forethought. To better manage this process, we are moving to 
an electronic on-line, web based procedure manual with document control 
functions that tracks usage by employee and captures electronic signatures for 
each step of the creation, review and implementation process. Thankfully, this 
process is the responsibility of our Technical Specialist for Anatomic 
Pathology and our System Quality Department.


William DeSalvo, B.S., HTL(ASCP)





 Date: Wed, 22 Dec 2010 15:16:37 -0800
 From: vic...@pathology.washington.edu
 To: Histonet@lists.utsouthwestern.edu
 CC: 
 Subject: [Histonet] CAP Question regarding procedure manual
 
 Is there a requirement to have a signature of every staff member on a 
 procedure if they perform that procedure in a manual? Wouldn't one 
 signature on a cover page suffice that you have read and understand what 
 is in the manual?
 
 Victor
 
 -- 
 Victor Tobias
 Clinical Applications Analyst
 University of Washington Medical Center
 Dept of Pathology Room BB220
 1959 NE Pacific
 Seattle, WA 98195
 vic...@pathology.washington.edu
 206-598-2792
 206-598-7659 Fax
 =
 Privileged, confidential or patient identifiable information may be
 contained in this message. This information is meant only for the use
 of the intended recipients. If you are not the intended recipient, or
 if the message has been addressed to you in error, do not read,
 disclose, reproduce, distribute, disseminate or otherwise use this
 transmission. Instead, please notify the sender by reply e-mail, and
 then destroy all copies of the message and any attachments.
 
 
 ___
 Histonet mailing list
 Histonet@lists.utsouthwestern.edu
 http://lists.utsouthwestern.edu/mailman/listinfo/histonet
  
___
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Histonet@lists.utsouthwestern.edu
http://lists.utsouthwestern.edu/mailman/listinfo/histonet

RE: [Histonet] CAP Question regarding procedure manual

[Jesus Ellin]

Currently Victor we use to have the techs sign off on all the policies
and procedures.  As Bill stated this is a big pain.  We are now all
electonic and have gone live with I-Passport our document control
software,, this has saved tons of time and effort.  Electronic is the
way to go especially for updates and new information.  Users are notifed
by email and it allows the supervisor to keep track of edits and much
more. 


 

Jesus A Ellin  HT/PA  ASCP

Department of Pathology/Histology

Yuma Regional Medical Center

2400 South Ave A

Yuma, AZ  85364 - 7170

( Office:  (928) 336-1743

(Fax:  (928) 336-7319

*Email: jel...@yumaregional.org 


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of WILLIAM
DESALVO
Sent: Wednesday, December 22, 2010 4:46 PM
To: vic...@pathology.washington.edu; histonet
Subject: RE: [Histonet] CAP Question regarding procedure manual


You will need a signature for the manual and for each procedure that is
implemented or amended during your cycle year. If your manual is very
stable, a yearly signature page for the entire manual may suffice, but
the inspector will note the date everyone signed the manual review page
and then go through the manual to see if there are any implementation
dates or procedure change dates after the manual review date. Each
occurrence found one can be a deficiency.

In my lab, it is not uncommon for new procedures to be written and
implemented or existing procedures implemented during a cycle year and
all these events require a signature by System Medical Director, Site
Medical Director, Site Lab Director, System Technical Specialist
(responsible for physically writing) and all employees affected. You
must prove to CAP that all personnel know where the procedure manual is
located, that they have reviewed the manual as a whole and that they
have reviewed all additions implemented. We have employees sign each
technical alert, procedure update/change and new procedures, along with
a once a year review of all manuals.

This type of signature trail is part of and right in line with quality
management and document control. This process alone can be a daunting
task and requires a lot or forethought. To better manage this process,
we are moving to an electronic on-line, web based procedure manual with
document control functions that tracks usage by employee and captures
electronic signatures for each step of the creation, review and
implementation process. Thankfully, this process is the responsibility
of our Technical Specialist for Anatomic Pathology and our System
Quality Department.


William DeSalvo, B.S., HTL(ASCP)





 Date: Wed, 22 Dec 2010 15:16:37 -0800
 From: vic...@pathology.washington.edu
 To: Histonet@lists.utsouthwestern.edu
 CC: 
 Subject: [Histonet] CAP Question regarding procedure manual
 
 Is there a requirement to have a signature of every staff member on a 
 procedure if they perform that procedure in a manual? Wouldn't one 
 signature on a cover page suffice that you have read and understand 
 what is in the manual?
 
 Victor
 
 --
 Victor Tobias
 Clinical Applications Analyst
 University of Washington Medical Center Dept of Pathology Room BB220
 1959 NE Pacific
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[Histonet] CAP question ANP.22970

[Cathy . Crumpton]

   How  is  everyone  handling  this new question about Annual Result Co   
mparison  for  ER  and  PR?  The question states ...the laboratory at
   lea=   st   annually  compares  its  patient  results  with  published
   benchmarks,  and  eva=  luates  interobserver  variability  among  the
   pathologists  in the laboratory..= .  Do you have a separate computer
   program or do this by hand?

   = DIV

   Cathy Crumpton HT(ASCP), Histology Lead
   Tuality= Community Hospital
   Hillsboro, OR 97123
   (503)681-1292

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RE: [Histonet] CAP question ANP.22970

[McMahon, Loralee A]

We do this by hand.  Usually it involves a summer student to compile all of the 
data on a spread sheet and a formula to compute the percentage of positive 
cases. 

Loralee McMahon, HTL (ASCP)
Immunohistochemistry Supervisor
Strong Memorial Hospital
Department of Surgical Pathology
(585) 275-7210

From: histonet-boun...@lists.utsouthwestern.edu 
[histonet-boun...@lists.utsouthwestern.edu] On Behalf Of 
cathy.crump...@tuality.org [cathy.crump...@tuality.org]
Sent: Thursday, October 21, 2010 1:33 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP question ANP.22970

   How  is  everyone  handling  this new question about Annual Result Co   
mparison  for  ER  and  PR?  The question states ...the laboratory at
   lea=   annually  compares  its  patient  results  with  published
   benchmarks,  and  eva=ates  interobserver  variability  among  the
   pathologists  in the laboratory..=  Do you have a separate computer
   program or do this by hand?

   =V

   Cathy Crumpton HT(ASCP), Histology Lead
   Tuality=mmunity Hospital
   Hillsboro, OR 97123
   (503)681-1292

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RE: [Histonet] CAP question ANP.22970

[Martha Ward]

We are doing it by hand as well, into a spread sheet, and then doing the
calculations.   


Martha Ward, MT (ASCP) QIHC
Assistant Manager, Molecular Diagnostics Lab
Wake Forest University Baptist Medical Center
336-716-2104
 
 

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of McMahon,
Loralee A
Sent: Thursday, October 21, 2010 1:57 PM
To: cathy.crump...@tuality.org; histonet@lists.utsouthwestern.edu
Subject: RE: [Histonet] CAP question ANP.22970

We do this by hand.  Usually it involves a summer student to compile all
of the data on a spread sheet and a formula to compute the percentage of
positive cases. 

Loralee McMahon, HTL (ASCP)
Immunohistochemistry Supervisor
Strong Memorial Hospital
Department of Surgical Pathology
(585) 275-7210

From: histonet-boun...@lists.utsouthwestern.edu
[histonet-boun...@lists.utsouthwestern.edu] On Behalf Of
cathy.crump...@tuality.org [cathy.crump...@tuality.org]
Sent: Thursday, October 21, 2010 1:33 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP question ANP.22970

   How  is  everyone  handling  this new question about Annual Result Co
mparison  for  ER  and  PR?  The question states ...the laboratory at
   lea=   annually  compares  its  patient  results  with  published
   benchmarks,  and  eva=ates  interobserver  variability  among  the
   pathologists  in the laboratory..=  Do you have a separate computer
   program or do this by hand?

   =V

   Cathy Crumpton HT(ASCP), Histology Lead
   Tuality=mmunity Hospital
   Hillsboro, OR 97123
   (503)681-1292

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[Histonet] CAP question

[Kathy M. Gorham]

This will be my first CAP inspection.  We are switching from JCAHO.
Somewhere I read that we need to have a grossing room manual that would
have all the procedures on how to gross anything and everything that
would come through the Histology Lab. Is this true? Does anyone have a
sample that they are willing to share with me?  Thanks, 

Kathy Gorham H.T.
Grande Ronde Hospital
La Grande, OR  


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[Histonet] Cap Question: 2 identifiers for slides

[Scott, Allison D]

Is is a CAP requirement to have 2 identifiers on surgical slides?

Allison Scott HT(ASCP)
Histology Supervisor
LBJ Hospital
Houston, Texas 77026
713-566-5287
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[Histonet] CAP question

[DKBoyd]

We are no longer CAP inspected but Joint Commission.  Could someone tell 
me what the CAP standard for breast biopsies states about  formalin 
fixation?ie:  24 hrs, 36 hrs etc.
Thanks.
 
Debbie M. Boyd, HT(ASCP) l Chief Histologist l Southside Regional Medical 
Center I 
200 Medical Park Boulevard l Petersburg, Va.  23805 l T: 804-765-5050 l F: 
804-765-5582 l dkb...@chs.net





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RE: [Histonet] CAP question

[Mike Pence]

Here it is from CAP:


ANP.22998 Phase I   N/A   YES   NO

If the laboratory assesses HER2 protein over-expression by
immunohistochemistry (IHC) or HER2 gene amplification by fluorescence in
situ hybridization (FISH), does the laboratory have a documented
procedure for ensuring appropriate length of fixation of specimens
tested?  

NOTE:  Specimens subject to HER2 testing should be fixed in 10% neutral
buffered formalin for at least 6 hours and no longer than 48 hours.
While core biopsies must not be fixed for less than 1 hour, it is
recommended that such specimens have the same fixation as larger
specimens (i.e., 6 hours minimum).  It is recommended that time of
fixation be recorded and included in the report if available. While the
maximum fixation time of 48 hours is not an exclusion criterion for HER2
testing, laboratories should qualify any negative results for specimens
fixed longer than 48 hours.  For cases with negative results by IHC,
consideration should be given to performing confirmatory analysis by
FISH.

Laboratories testing specimens obtained from another institution should
have a policy that addresses time of fixation.  Information on time of
fixation may be obtained by appropriate questions on the laboratory's
requisition form.  The time of fixation should be recorded in the final
report. 

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of
dkb...@chs.net
Sent: Monday, January 18, 2010 10:59 AM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP question


We are no longer CAP inspected but Joint Commission.  Could someone tell

me what the CAP standard for breast biopsies states about  formalin 
fixation?ie:  24 hrs, 36 hrs etc.
Thanks.
 
Debbie M. Boyd, HT(ASCP) l Chief Histologist l Southside Regional
Medical 
Center I 
200 Medical Park Boulevard l Petersburg, Va.  23805 l T: 804-765-5050 l
F: 
804-765-5582 l dkb...@chs.net






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[Histonet] cap question amp.12087

[anita dudley]

just wondering if everyone is defrosting their cryostats every week?  seems 
like overkill, we clean ours out daily and every week clean with 100 alc.  what 
are others doing?  this is a revised question.  thanks a lot  

anita dudley

providence hospital

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Re: [Histonet] CAP question

[Drew Meyer]

There has already been a lot of responses to this, but I thought I'd
add mine anyway.

For all our specimens in-house that are delivered from surgery, we
have three identifiers present: name, DOB and MR number.  We
eliminated the use of SSN (from our reports as well), since we all
know how dangerous it is to have your SSN just floating around.

Specimens received from outside facilities are a little different,
because the outside facility can't possibly label the specimen with
our MR number; it's assigned once the specimen arrives at our
location.  In those instances, just the name and DOB are used.

At the time of accession, we do add the in-house pathology case number
to all the specimens as well.  You might call this overkill, but it
helps greatly when we need to pull a specimen later on and it helps
cut down on grossing errors.

The big thing from CAP is the two identifiers.  When you're
specifically dealing with outpatient centers where you might not be
able to get the medical record number on the container at the time of
collection, it seems to me that the best choice is to use name and
DOB.  Just my 2 cents.

Drew

On Wed, Dec 2, 2009 at 11:49, Una McGiven lost.dragon...@yahoo.com wrote:
 Hi everyone,

 On the most recent CAP checklist there is a requirement for 2 patient 
 identifiers.  For those labs who are CAP and receive all or a large portion 
 of their cases from outside facilities (=not from your facility), what are 
 you using as the identifiers on your specimen containers?  Name and 
 birthdate?  SS#?  Med record?  Something else?

 Thank you in advance!



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RE: [Histonet] CAP question

[Inman, Anna]

 Yes, patient name, DOB or SS#  and the case number and such is extra 

 

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Weems,
Joyce
Sent: Wednesday, December 02, 2009 10:41 AM
To: histonet@lists.utsouthwestern.edu
Subject: RE: [Histonet] CAP question

 

Don't we still need to follow through with two identifiers tho? 

 



 

From: Inman, Anna [mailto:anna.in...@stmarygj.org] 

Sent: Wednesday, December 02, 2009 12:16

To: Lois Anderson; Weems, Joyce; histonet@lists.utsouthwestern.edu

Subject: RE: [Histonet] CAP question

 

 

 

 Keep in mind: 

 

 The requirement states 2 patient identifiers at the time of collection

- so the identifiers need to come from the outside entities. 

 

My conversation with CAP - they are going for patient name, DOB, SS# or

medical record number of some sort that ties the hospital to the

clinician office. 

 

If the case number or med record number does not get joined until it

reaches your facility - it does not meet the CAP requirement. 

 

 

 

We are asking for patient name and DOB 

 

 

 

 

 

 

 

-Original Message-

From: histonet-boun...@lists.utsouthwestern.edu

[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Lois

Anderson

Sent: Wednesday, December 02, 2009 10:04 AM

To: Weems, Joyce; histonet@lists.utsouthwestern.edu

Subject: RE: [Histonet] CAP question

 

 

 

Name and case number or med records number

 

 

 

-Original Message-

 

From: histonet-boun...@lists.utsouthwestern.edu

[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Weems,

Joyce

 

Sent: Wednesday, December 02, 2009 12:00 PM

 

To: histonet@lists.utsouthwestern.edu

 

Subject: RE: [Histonet] CAP question

 

 

 

Case number and name

 

 

 

-Original Message-

 

From: histonet-boun...@lists.utsouthwestern.edu

[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Una

McGiven

 

Sent: Wednesday, December 02, 2009 11:50

 

To: histonet@lists.utsouthwestern.edu

 

Subject: [Histonet] CAP question

 

 

 

Hi everyone,

 

 

 

On the most recent CAP checklist there is a requirement for 2 patient

identifiers.  For those labs who are CAP and receive all or a large

portion of their cases from outside facilities (=not from your

facility), what are you using as the identifiers on your specimen

containers?  Name and birthdate?  SS#?  Med record?  Something else?

 

 

 

Thank you in advance!

 

 

 

 

 

  

 

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RE: [Histonet] CAP question

[Rene J Buesa]

Because those whose SS# are for everybody to see do not know!
René J.

--- On Wed, 12/2/09, Sebree Linda A lseb...@uwhealth.org wrote:


From: Sebree Linda A lseb...@uwhealth.org
Subject: RE: [Histonet] CAP question
To: Rene J Buesa rjbu...@yahoo.com, JoyceWeems jwe...@sjha.org, 
histonet@lists.utsouthwestern.edu, AnnaInman anna.in...@stmarygj.org
Date: Wednesday, December 2, 2009, 4:32 PM


Leads me to wonder how the VA gets away with using SS#s as identifiers!

Linda A. Sebree
University of Wisconsin Hospital  Clinics
IHC/ISH Laboratory
DB1-223 VAH
600 Highland Ave.
Madison, WI 53792
(608)265-6596



-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Rene J Buesa
Sent: Wednesday, December 02, 2009 3:21 PM
To: JoyceWeems; histonet@lists.utsouthwestern.edu; AnnaInman
Subject: RE: [Histonet] CAP question


I would strongly suggest not using the SS# as a second identifier. That is a 
piece of information the patient gave to the hospital but I am sure the patient 
would not like to see written in a cassette/slide for all to see (and copy). 
René J.

--- On Wed, 12/2/09, Inman, Anna anna.in...@stmarygj.org wrote:


From: Inman, Anna anna.in...@stmarygj.org
Subject: RE: [Histonet] CAP question
To: Weems, Joyce jwe...@sjha.org, histonet@lists.utsouthwestern.edu
Date: Wednesday, December 2, 2009, 3:05 PM


Yes, patient name, DOB or SS#  and the case number and such is extra 



-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Weems, Joyce
Sent: Wednesday, December 02, 2009 10:41 AM
To: histonet@lists.utsouthwestern.edu
Subject: RE: [Histonet] CAP question



Don't we still need to follow through with two identifiers tho? 







From: Inman, Anna [mailto:anna.in...@stmarygj.org] 

Sent: Wednesday, December 02, 2009 12:16

To: Lois Anderson; Weems, Joyce; histonet@lists.utsouthwestern.edu

Subject: RE: [Histonet] CAP question







Keep in mind: 



The requirement states 2 patient identifiers at the time of collection

- so the identifiers need to come from the outside entities. 



My conversation with CAP - they are going for patient name, DOB, SS# or

medical record number of some sort that ties the hospital to the

clinician office. 



If the case number or med record number does not get joined until it

reaches your facility - it does not meet the CAP requirement. 







We are asking for patient name and DOB 















-Original Message-

From: histonet-boun...@lists.utsouthwestern.edu

[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Lois

Anderson

Sent: Wednesday, December 02, 2009 10:04 AM

To: Weems, Joyce; histonet@lists.utsouthwestern.edu

Subject: RE: [Histonet] CAP question







Name and case number or med records number







-Original Message-



From: histonet-boun...@lists.utsouthwestern.edu

[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Weems,

Joyce



Sent: Wednesday, December 02, 2009 12:00 PM



To: histonet@lists.utsouthwestern.edu



Subject: RE: [Histonet] CAP question







Case number and name







-Original Message-



From: histonet-boun...@lists.utsouthwestern.edu

[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Una

McGiven



Sent: Wednesday, December 02, 2009 11:50



To: histonet@lists.utsouthwestern.edu



Subject: [Histonet] CAP question







Hi everyone,







On the most recent CAP checklist there is a requirement for 2 patient

identifiers.  For those labs who are CAP and receive all or a large

portion of their cases from outside facilities (=not from your

facility), what are you using as the identifiers on your specimen

containers?  Name and birthdate?  SS#?  Med record?  Something else?







Thank you in advance!











      



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[Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathology reports

[Foshey, Annette]

What is the current practice for meeting this regulation?  Is a general 
statement (disclaimer) placed on all pathology reports that have 
immunocytochemistry and/or
FISH and ISH or is the disclaimer placed only on the reports where the class 1 
ASR antibody or nucleic acid have been used?

Thanks for your input?
Annette Foshey
Charge Tech in Histology
Children's Hospital of Wisconsin
414-266-6580Fax 414-266-2779
afos...@chw.org


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Re: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathology reports

[Rene J Buesa]

We used to add that the methods were experimental.
René J.

--- On Fri, 11/20/09, Foshey, Annette afos...@chw.org wrote:


From: Foshey, Annette afos...@chw.org
Subject: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathology reports
To:  (histonet@lists.utsouthwestern.edu) histonet@lists.utsouthwestern.edu
Date: Friday, November 20, 2009, 12:54 PM


What is the current practice for meeting this regulation?  Is a general 
statement (disclaimer) placed on all pathology reports that have 
immunocytochemistry and/or
FISH and ISH or is the disclaimer placed only on the reports where the class 1 
ASR antibody or nucleic acid have been used?

Thanks for your input?
Annette Foshey
Charge Tech in Histology
Children's Hospital of Wisconsin
414-266-6580        Fax 414-266-2779
afos...@chw.org


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RE: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathologyreports

[Weems, Joyce]

We add ours to only the Class I ASR cases. 

Joyce Weems 
Pathology Manager 
Saint Joseph's Hospital 
5665 Peachtree Dunwoody Rd NE 
Atlanta, GA 30342 
678-843-7376 - Phone 
678-843-7831 - Fax 



-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Foshey,
Annette
Sent: Friday, November 20, 2009 12:55
To: (histonet@lists.utsouthwestern.edu)
Subject: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on
pathologyreports

What is the current practice for meeting this regulation?  Is a general
statement (disclaimer) placed on all pathology reports that have
immunocytochemistry and/or FISH and ISH or is the disclaimer placed only
on the reports where the class 1 ASR antibody or nucleic acid have been
used?

Thanks for your input?
Annette Foshey
Charge Tech in Histology
Children's Hospital of Wisconsin
414-266-6580Fax 414-266-2779
afos...@chw.org


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RE: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathologyreports

[Martha Ward]

We use the statement for all reports that any IHC/ISH, regardless if
they are ASRs or not.

Martha Ward
Wake Forest University Baptist Medical Center 

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Foshey,
Annette
Sent: Friday, November 20, 2009 12:55 PM
To: (histonet@lists.utsouthwestern.edu)
Subject: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on
pathologyreports

What is the current practice for meeting this regulation?  Is a general
statement (disclaimer) placed on all pathology reports that have
immunocytochemistry and/or FISH and ISH or is the disclaimer placed only
on the reports where the class 1 ASR antibody or nucleic acid have been
used?

Thanks for your input?
Annette Foshey
Charge Tech in Histology
Children's Hospital of Wisconsin
414-266-6580Fax 414-266-2779
afos...@chw.org


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RE: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathology reports

[Morken, Tim]

The disclaimer is only for ASR antibodies. They don't have to be labeled 
experimental because a CLIA certified lab has full capability and authority 
to validate any antibody they want to use for any purpose. You do have to 
document your validation procedure and results.

You can also use RUO antibodies under CLIA regs as long as you do the full 
documented validation. Interestingly there is no suggested disclaimer for RUO 
antibodies. 

Tim Morken
Supervisor, Histology / IPOX
UCSF Medical Center
San Francisco, CA  
 

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Foshey, Annette
Sent: Friday, November 20, 2009 9:55 AM
To: (histonet@lists.utsouthwestern.edu)
Subject: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathology reports

What is the current practice for meeting this regulation?  Is a general 
statement (disclaimer) placed on all pathology reports that have 
immunocytochemistry and/or
FISH and ISH or is the disclaimer placed only on the reports where the class 1 
ASR antibody or nucleic acid have been used?

Thanks for your input?
Annette Foshey
Charge Tech in Histology
Children's Hospital of Wisconsin
414-266-6580Fax 414-266-2779
afos...@chw.org


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RE: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer onpathology reports

[Weems, Joyce]

Just can't bill for RUO, correct? 

 

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Morken,
Tim
Sent: Friday, November 20, 2009 13:24
To: Foshey, Annette; (histonet@lists.utsouthwestern.edu)
Subject: RE: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer
onpathology reports

The disclaimer is only for ASR antibodies. They don't have to be labeled
experimental because a CLIA certified lab has full capability and
authority to validate any antibody they want to use for any purpose. You
do have to document your validation procedure and results.

You can also use RUO antibodies under CLIA regs as long as you do the
full documented validation. Interestingly there is no suggested
disclaimer for RUO antibodies. 

Tim Morken
Supervisor, Histology / IPOX
UCSF Medical Center
San Francisco, CA  
 

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Foshey,
Annette
Sent: Friday, November 20, 2009 9:55 AM
To: (histonet@lists.utsouthwestern.edu)
Subject: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathology
reports

What is the current practice for meeting this regulation?  Is a general
statement (disclaimer) placed on all pathology reports that have
immunocytochemistry and/or FISH and ISH or is the disclaimer placed only
on the reports where the class 1 ASR antibody or nucleic acid have been
used?

Thanks for your input?
Annette Foshey
Charge Tech in Histology
Children's Hospital of Wisconsin
414-266-6580Fax 414-266-2779
afos...@chw.org


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Re: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer onpathology reports

[Joe Nocito]

I have a question similar to this one.
If I take 2 IVD antibodies say cytokeratin AE1/AE3 and 34BF12 and make these 
into one cytokeratin cocktail, is this considered an ASR because I combined 
them into another antibody?


Joe
- Original Message - 
From: Morken, Tim timothy.mor...@ucsfmedctr.org

To: Foshey, Annette afos...@chw.org; histonet@lists.utsouthwestern.edu
Sent: Friday, November 20, 2009 12:24 PM
Subject: RE: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer onpathology 
reports



The disclaimer is only for ASR antibodies. They don't have to be labeled 
experimental because a CLIA certified lab has full capability and 
authority to validate any antibody they want to use for any purpose. You do 
have to document your validation procedure and results.


You can also use RUO antibodies under CLIA regs as long as you do the full 
documented validation. Interestingly there is no suggested disclaimer for 
RUO antibodies.


Tim Morken
Supervisor, Histology / IPOX
UCSF Medical Center
San Francisco, CA


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Foshey, 
Annette

Sent: Friday, November 20, 2009 9:55 AM
To: (histonet@lists.utsouthwestern.edu)
Subject: [Histonet] CAP QUESTION ANP.12425 ASR disclaimer on pathology 
reports


What is the current practice for meeting this regulation?  Is a general 
statement (disclaimer) placed on all pathology reports that have 
immunocytochemistry and/or
FISH and ISH or is the disclaimer placed only on the reports where the class 
1 ASR antibody or nucleic acid have been used?


Thanks for your input?
Annette Foshey
Charge Tech in Histology
Children's Hospital of Wisconsin
414-266-6580Fax 414-266-2779
afos...@chw.org


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[Histonet] CAP Question

[Laurie Colbert]

I would like to know how others interpret this CAP question ANP.21350:
Does the histology laboratory maintain records of the number of blocks,
slides, and stains prepared

 

As far as the stains go - do you interpret this to mean do you keep
track of the number of stains performed (as in, how many special stains
do you do a year), or do you keep track of the number of stock stain
solutions actually prepared?

 

Laurie Colbert

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RE: [Histonet] CAP Question

[Jodie Robertson]

How many slides you do a year is what we did and it passed CAP.  We keep
track of how many special stains, IHC and HE a year in slides.


Jodie Robertson, HT (ASCP) QIHC
Pathology Sciences Medical Group
-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Laurie
Colbert
Sent: Wednesday, May 06, 2009 11:32 AM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP Question

I would like to know how others interpret this CAP question ANP.21350:
Does the histology laboratory maintain records of the number of blocks,
slides, and stains prepared

 

As far as the stains go - do you interpret this to mean do you keep
track of the number of stains performed (as in, how many special stains
do you do a year), or do you keep track of the number of stock stain
solutions actually prepared?

 

Laurie Colbert

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Re: [Histonet] CAP Question

[Rene J Buesa]

That is a quantifying question by CAP and refers to keeping track of the number 
of blocks processed and slides stained either routine (HE) or special 
procedures (HC, IHC) daily to get to a monthly and annual figures.
CAP does not care about the stocks prepared because how you use your stock 
solutions is another aspect of the QA.
René J.

--- On Wed, 5/6/09, Laurie Colbert laurie.colb...@huntingtonhospital.com 
wrote:

From: Laurie Colbert laurie.colb...@huntingtonhospital.com
Subject: [Histonet] CAP Question
To: histonet@lists.utsouthwestern.edu
Date: Wednesday, May 6, 2009, 2:31 PM

I would like to know how others interpret this CAP question ANP.21350:
Does the histology laboratory maintain records of the number of blocks,
slides, and stains prepared

 

As far as the stains go - do you interpret this to mean do you keep
track of the number of stains performed (as in, how many special stains
do you do a year), or do you keep track of the number of stock stain
solutions actually prepared?

 

Laurie Colbert

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[Histonet] CAP question

[Mary Abosso]

Hi all,  I am updating procedures and am wondering if there is a better format 
for compliance with 
 

ANP.22250 - Does the procedure manual address all methods and antibodies 
currently in use?

 

Just wondering if I need to include every antibody or a generic procedure 
covering most antibodies, with the exceptions only reference within the same 
procedure?

 

Any help would be appreciated.

 

Thanks,

Mary Abosso

 

 

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Re: [Histonet] CAP question

[Amy Porter]

Mary - I have one generic protocol with a spreadsheet attached stating the 
following:

Name of Antibody
CD/CK #
Clone
Species
Pretreatment
Dilution
Incubation time
Enzyme (ABC or AP)
Lot # in Use

Hope this helps out it has passed in the past.  take care.  amy


Amy S. Porter, HT (ASCP) QIHC
Investigative HistoPathology Laboratory - Supervisor
2201 Biomedical Physical Sciences Bldg.  Rm #2133
East Lansing, MI  48824-3320
Phone:  (517) 884-5026
Fax:  (517) 432-1368
Email:  port...@msu.edu
Web:  www.humanpathology.msu.edu
- Original Message - 
From: Mary Abosso mabo...@unipathllc.com

To: Histonet histonet@lists.utsouthwestern.edu
Sent: Wednesday, April 22, 2009 1:30 PM
Subject: [Histonet] CAP question


Hi all,  I am updating procedures and am wondering if there is a better 
format for compliance with



ANP.22250 - Does the procedure manual address all methods and antibodies 
currently in use?




Just wondering if I need to include every antibody or a generic procedure 
covering most antibodies, with the exceptions only reference within the same 
procedure?




Any help would be appreciated.



Thanks,

Mary Abosso





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Re: [Histonet] CAP question

[Rene J Buesa]

I used to have a generic protocol for each type of procedure. For example: the 
lectin procedure for Ulex europaeus was summarized apart for the general used 
with most
of the Abs using HIER. There was also a general protocol when the procedure was 
completed manually of with the Dako autostainer that we used.The procedure for 
Her2-neu was also apart.
Also I had a spread sheet for the different antibodies in use and for each it 
was stated the HIER pH required and other relevant data for the antigen, as 
well as the type of control used.
René J.

--- On Wed, 4/22/09, Mary Abosso mabo...@unipathllc.com wrote:

From: Mary Abosso mabo...@unipathllc.com
Subject: [Histonet] CAP question
To: Histonet histonet@lists.utsouthwestern.edu
Date: Wednesday, April 22, 2009, 1:30 PM

Hi all,  I am updating procedures and am wondering if there is a better format
for compliance with 
 

ANP.22250 - Does the procedure manual address all methods and antibodies
currently in use?

 

Just wondering if I need to include every antibody or a generic procedure
covering most antibodies, with the exceptions only reference within the same
procedure?

 

Any help would be appreciated.

 

Thanks,

Mary Abosso

 

 

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RE: [Histonet] CAP Question

[WILLIAM DESALVO]

I suggest that you  use your biomedical depatment. You need to establish a 
consistent process and then stick to it.

 Date: Wed, 24 Sep 2008 13:01:18 -0700 From: [EMAIL PROTECTED] To: 
 histonet@lists.utsouthwestern.edu; [EMAIL PROTECTED] Subject: Re: [Histonet] 
 CAP Question CC:   You should have your instruments checked on a regular 
 basis. In our hospital we used the services of our engineering department, 
 but you can contract a specialized company to do that. After each general 
 maintenance, the results are logged in a special form you develop for each 
 instrument. René J.  --- On Wed, 9/24/08, [EMAIL PROTECTED] [EMAIL 
 PROTECTED] wrote:  From: [EMAIL PROTECTED] [EMAIL PROTECTED] Subject: 
 [Histonet] CAP Question To: histonet@lists.utsouthwestern.edu Date: 
 Wednesday, September 24, 2008, 3:26 PM  I am going through the CAP 
 checklist and came upon this question:  ANP23075:? Is there evidence of 
 ongoing evaluation of results of instrumetn maintenance and function for all 
 devices?  The question before it asks if service reports are kept and they 
 are.? How do I respond to this question other than the equipment works after 
 being serviced!!!? Any ideas?  Thank you, Ann 
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