Re: [Histonet] CAP Cytopathology checklist question

[Hannen, Valerie via Histonet]

Good Morning Lacy,

Thank you for the sharing your policy,  it will be very helpful in creating my 
own.


-Original Message-
From: Normington, Lacy  
Sent: Thursday, November 30, 2023 9:08 AM
To: Hannen, Valerie ; 
Histonet@lists.utsouthwestern.edu
Subject: [EXTERNAL] RE: CAP Cytopathology checklist question


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Hello Valerie,
Here is the policy we created to meet this question.

Standardized criteria for specimen adequacy are applied where available. This 
includes the Paris System for Reporting Urinary Cytology, the Bethesda System 
for reporting Anal/Rectal Cytology, and the Bethesda System for reporting 
Thyroid Cytopathology. The additional criteria below apply to all other 
non-gynecological specimen types.

1. A specimen is unsatisfactory if there's an absence of abnormal cells AND any 
of the following criteria are met:
* The complete absence of cellular material.
* Insufficient cellular material present to verify the source of the specimen 
(i.e.
mesothelial cells in a serous fluid, alveolar macrophages in a BAL, etc.).
* The absence of lymphocytes in a lymph node FNA
* The presence of benign cellular material on an FNA that cannot explain a 
clinically suspicious mass or lesion.

2. All unsatisfactory non-gynecologic specimens include a description of the 
specimen's limitations (i.e. low cellularity).

References
1. Rosenthal D, Wojcik EM, Kurtycz DF. The Paris system for reporting urinary 
cytology.
Switzerland: Springer International Publishing; 2016.
2. Nayar R, Wilbur DC. The Bethesda system for reporting cervical cytology - 
definitions, criteria, and explanatory notes. 3rd ed. Switzerland: Springer 
International Publishing; 2015.
3. Ali SZ, Cibas ES. The Bethesda System for Reporting Thyroid Cytopathology. 
New York,
NY: Springer; 2010.

-Original Message-
From: Hannen, Valerie via Histonet 
Sent: Wednesday, November 29, 2023 2:41 PM
To: Histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP Cytopathology checklist question

WARNING: This email appears to have originated outside of the UW Health email 
system.
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Hello Everyone,

I am hoping you can help me.  I am very confused by one of the questions in our 
CAP Cytopathology question. How are you handling/ answering this question in 
the NON-GYNCOLOGIC CYTOPATHLOOGY Section?  The question is CYP.07666, 
Unsatisfactory Specimens- Non-gynecologic CytoPathology:
It states " The Laboratory follows defined criteria for identification and 
reporting of unsatisfactory non-gynecologic specimens, as applicable".  It 
shows that I must write a policy for this question.  Our  reports  do state the 
reason for being deemed a "unsatisfactory" specoimen.

Thank you in advance!!

Valerie

Valerie A. Hannen,MLT(ASCP),HTL,SU(FL)
Histology Section Chief
Parrish Medical Center
951 N. Washington Avenue
Titusville, Florida 32796
P: 321-268-6333  Ext. 7506
F: 321-268-6149
valerie.han...@parrishmed.com
http://www.parrishmed.com/

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Re: [Histonet] CAP Cytopathology checklist question

[Normington, Lacy via Histonet]

Hello Valerie,
Here is the policy we created to meet this question.

Standardized criteria for specimen adequacy are applied where available. This 
includes the
Paris System for Reporting Urinary Cytology, the Bethesda System for reporting 
Anal/Rectal
Cytology, and the Bethesda System for reporting Thyroid Cytopathology. The 
additional criteria
below apply to all other non-gynecological specimen types.

1. A specimen is unsatisfactory if there's an absence of abnormal cells AND any 
of the
following criteria are met:
* The complete absence of cellular material.
* Insufficient cellular material present to verify the source of the specimen 
(i.e.
mesothelial cells in a serous fluid, alveolar macrophages in a BAL, etc.).
* The absence of lymphocytes in a lymph node FNA
* The presence of benign cellular material on an FNA that cannot explain a 
clinically
suspicious mass or lesion.

2. All unsatisfactory non-gynecologic specimens include a description of the 
specimen's
limitations (i.e. low cellularity).

References
1. Rosenthal D, Wojcik EM, Kurtycz DF. The Paris system for reporting urinary 
cytology.
Switzerland: Springer International Publishing; 2016.
2. Nayar R, Wilbur DC. The Bethesda system for reporting cervical cytology - 
definitions,
criteria, and explanatory notes. 3rd ed. Switzerland: Springer International 
Publishing;
2015.
3. Ali SZ, Cibas ES. The Bethesda System for Reporting Thyroid Cytopathology. 
New York,
NY: Springer; 2010.

-Original Message-
From: Hannen, Valerie via Histonet 
Sent: Wednesday, November 29, 2023 2:41 PM
To: Histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP Cytopathology checklist question

WARNING: This email appears to have originated outside of the UW Health email 
system.
DO NOT CLICK on links or attachments unless you recognize the sender and know 
the content is safe.

Hello Everyone,

I am hoping you can help me.  I am very confused by one of the questions in our 
CAP Cytopathology question. How are you handling/ answering this question in 
the NON-GYNCOLOGIC CYTOPATHLOOGY Section?  The question is CYP.07666, 
Unsatisfactory Specimens- Non-gynecologic CytoPathology:
It states " The Laboratory follows defined criteria for identification and 
reporting of unsatisfactory non-gynecologic specimens, as applicable".  It 
shows that I must write a policy for this question.  Our  reports  do state the 
reason for being deemed a "unsatisfactory" specoimen.

Thank you in advance!!

Valerie

Valerie A. Hannen,MLT(ASCP),HTL,SU(FL)
Histology Section Chief
Parrish Medical Center
951 N. Washington Avenue
Titusville, Florida 32796
P: 321-268-6333  Ext. 7506
F: 321-268-6149
valerie.han...@parrishmed.com
http://www.parrishmed.com/

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Re: [Histonet] CAP regulatory question

[Cooper, Brian via Histonet]

Hi Jessica, 

That's the way we read it here, but in most cases we have probably more like 3 
years-worth. 

Thanks, 

Brian D. Cooper, HT (ASCP)CMQIHCCM| 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 

Thanks, 

Brian

-Original Message-
From: Piche, Jessica via Histonet  
Sent: Thursday, February 2, 2023 9:13 AM
To: Histonet 
Subject: [Histonet] CAP regulatory question (EXTERNAL EMAIL)

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

Good Afternoon,

Do we only have to keep lot to lot comparisons for immunohistochemistry and 
special stains for 2 years?

I hope everyone is having a good day.

Thank you.

Jessica

Jessica Piche, HT(ASCP)
Waterbury Hospital Histology Laboratory
Histology Team Leader
203-573-7167
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Re: [Histonet] CAP required PT

[Joe W. Walker, Jr. via Histonet]

In the June 2020 Checklists, it has been moved to the Commons as COM.01520

Joe W. Walker, Jr. MS, SCT(ASCP) 
Anatomical Pathology and Interim Phlebotomy Manager
Rutland Regional Medical Center
160 Allen Street, Rutland, VT 05701
P 802.747.1790  F 802.747.6525
joewal...@rrmc.org, www.rrmc.org

-Original Message-
From: Garrey Faller  
Sent: Friday, October 9, 2020 11:35 AM
To: Joe W. Walker, Jr. 
Subject: Re: [Histonet] CAP required PT

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Hi joe,
Can you point me to the cap reg for this? I can’t find it in the ap checklist. 
Is it in all common?
Thanks.
Garrey

Sent from my iPhone

> On Oct 9, 2020, at 10:49 AM, Joe W. Walker, Jr. via Histonet 
>  wrote:
>
> Any IHC that involves prognostic indications requires PT.  A short 
> list would include ER, PgR, HER2 but there are others. CAP info is 
> here: 
> https://urldefense.com/v3/__https://documents.cap.org/documents/2021-S
> urveys-catalog-mobile.pdf__;!!I87qwjxLstg3H_X5!v4MZvbrMCG7Y_tKHna_HwzE
> HdcLZmuhYM0UllgXIW6tQcPbpGothba-dAsQAxd8$
>
> Joe W. Walker, Jr. MS, SCT(ASCP)
> Anatomical Pathology and Interim Phlebotomy Manager Rutland Regional 
> Medical Center
> 160 Allen Street, Rutland, VT 05701
> P 802.747.1790  F 802.747.6525
> joewal...@rrmc.org, http://www.rrmc.org
>
> -Original Message-
> From: Wood, Barry A via Histonet 
> Sent: Thursday, October 8, 2020 2:25 PM
> To: 'Histonet@lists.utsouthwestern.edu' 
> 
> Subject: [Histonet] CAP required PT
>
> [External Email] This email originated from outside of the organization. 
> Think before you click: Don’t click on links, open attachments or respond to 
> requests for sensitive information if the email looks suspicious or you don’t 
> recognize the sender.
>
>
> For which IHC stains is it required by CAP to do proficiency testing?
>
> Barry Wood CT (ASCP)
> Director of Anatomic Pathology
> Indiana University Health
> 317-491-6351
> bw...@iuhealth.org<mailto:bw...@iuhealth.org>
> Compassionate. Highly skilled. Personalized. Visit iuhealth.org
>
>
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Re: [Histonet] CAP required PT

[Joe W. Walker, Jr. via Histonet]

Any IHC that involves prognostic indications requires PT.  A short list would 
include ER, PgR, HER2 but there are others. CAP info is here: 
https://documents.cap.org/documents/2021-Surveys-catalog-mobile.pdf

Joe W. Walker, Jr. MS, SCT(ASCP)
Anatomical Pathology and Interim Phlebotomy Manager
Rutland Regional Medical Center
160 Allen Street, Rutland, VT 05701
P 802.747.1790  F 802.747.6525
joewal...@rrmc.org, www.rrmc.org

-Original Message-
From: Wood, Barry A via Histonet 
Sent: Thursday, October 8, 2020 2:25 PM
To: 'Histonet@lists.utsouthwestern.edu' 
Subject: [Histonet] CAP required PT

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before you click: Don’t click on links, open attachments or respond to requests 
for sensitive information if the email looks suspicious or you don’t recognize 
the sender.


For which IHC stains is it required by CAP to do proficiency testing?

Barry Wood CT (ASCP)
Director of Anatomic Pathology
Indiana University Health
317-491-6351
bw...@iuhealth.org
Compassionate. Highly skilled. Personalized. Visit iuhealth.org


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Re: [Histonet] CAP inspection

[Joe W. Walker, Jr. via Histonet]

The CAP also offers an inspector training course, which provides lots of 
helpful information.  At one time this was a requirement to be a CAP inspector. 
 Not sure about this requirement anymore.

Joe W. Walker, Jr. MS, SCT(ASCP)
Anatomical Pathology and Interim Phlebotomy Manager
Rutland Regional Medical Center
160 Allen Street, Rutland, VT 05701
P 802.747.1790  F 802.747.6525
joewal...@rrmc.org, www.rrmc.org

-Original Message-
From: P Sicurello via Histonet 
Sent: Sunday, August 16, 2020 11:57 AM
To: samantha.gol...@hcahealthcare.com
Cc: HistoNet 
Subject: Re: [Histonet] CAP inspection

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the sender.


Hi Samantha,

Have "fun" with your first inspection.  A few pointers:  try not to compare the 
place you are inspecting with your lab, try to stay focused on the task at hand 
(many new inspectors are easily influenced), walk around and get a feel for the 
lab- sure they are going to be tense because of the CAP inspection - but look 
around - does anything feel off?, SDS's are a good thing to check - many places 
don't update theirs and the SDS is either not current or comes from a different 
vendor than the chemical in use.

You'll probably get lots of suggestions.

Stay safe.

Sincerely,

Paula Sicurello, HTL (ASCP)CM

Histotechnology Specialist

UC San Diego Health

9300 Campus Point Drive

La Jolla, CA 92037
(P): 858-249-5610



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On Sun, Aug 16, 2020 at 8:32 AM Samantha Golden, HT(ASCP) via Histonet < 
histonet@lists.utsouthwestern.edu> wrote:

> I’m excited to participate in my first CAP audit as part of the
> inspection team, and I would love some tips and advice for a first timer.
>
> I don’t want to get stuck in the weeds as to what I’m searching for.
> While I’ve read all the info from CAP regarding a successful
> inspection, I’d love some first hand experience from those who have done this.
>
> Thanks a bunch.
> Samantha Golden, BS, HT(ASCP)cmQIHCcm
>
>
> ---
> Sent from Workspace ONE
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Re: [Histonet] CAP inspection

[P Sicurello via Histonet]

Hi Samantha,

Have "fun" with your first inspection.  A few pointers:  try not to
compare the place you are inspecting with your lab, try to stay focused on
the task at hand (many new inspectors are easily influenced), walk around
and get a feel for the lab- sure they are going to be tense because of the
CAP inspection - but look around - does anything feel off?, SDS's are a
good thing to check - many places don't update theirs and the SDS is either
not current or comes from a different vendor than the chemical in use.

You'll probably get lots of suggestions.

Stay safe.

Sincerely,

Paula Sicurello, HTL (ASCP)CM

Histotechnology Specialist

UC San Diego Health

9300 Campus Point Drive

La Jolla, CA 92037
(P): 858-249-5610



*Confidentiality Notice*: The information transmitted in this e-mail is
intended only for the person or entity to which it is addressed and may
contain confidential and/or privileged material.  Any review,
retransmission, dissemination or other use of or taking of any action in
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please contact the sender and delete the material from any computer.


On Sun, Aug 16, 2020 at 8:32 AM Samantha Golden, HT(ASCP) via Histonet <
histonet@lists.utsouthwestern.edu> wrote:

> I’m excited to participate in my first CAP audit as part of the inspection
> team, and I would love some tips and advice for a first timer.
>
> I don’t want to get stuck in the weeds as to what I’m searching for. While
> I’ve read all the info from CAP regarding a successful inspection, I’d love
> some first hand experience from those who have done this.
>
> Thanks a bunch.
> Samantha Golden, BS, HT(ASCP)cmQIHCcm
>
>
> ---
> Sent from Workspace ONE Boxer
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Re: [Histonet] CAP proficiency testing

[John Garratt via Histonet]

The Canadian Pathology Quality Assurance programme runs IHC and FISH EQA 
internationally. We have performed PD-L1 EQA previously and we will be running 
a challenge January 2021. Previous EQA reports are available on line. Our 
website is www.cpqa.ca.
We work with regularity authorities to provide compliance information when 
requested by the participant.

John

On Thu, Apr 16, 2020 at 10:38 AM, Charles Riley via Histonet 
 wrote:

> Does anyone use another vendor besides CAP to perform their PT
> requirements?
>
> If so, who do you use and how do you record it for inspection purposes?
>
> I am looking for a PD-L1 PT specifically but will take any other options as
> well as we are trying to help our budget.
>
> --
>
> Charles Riley BS HT, HTL(ASCP)CM
>
> Histopathology Coordinator/ Mohs
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Re: [Histonet] CAP Cancer protocols and synoptic reporting

[Joe W. Walker, Jr. via Histonet]

Hi Amy,

We don't have a "policy" per se but we have a process in place to help meet 
these questions.  We utilize Cerner and have created a custom report that looks 
for cases that require a synoptic report to be used.  The report displays 
cancer cases where a synoptic report was not used. We have to then manually 
look at these cases and determine the reason why (non-melanoma case, biopsy 
specimen, etc.)  This list is provided to our cancer center and they perform a 
random 10% audit of these cases to ensure that all of the required elements 
were completed as required.  In order to ensure we are using the current 
synoptic report, we have an IT analyst who receives the synoptic report updates 
and updates our templates within the system.  As you can see, it is a complex 
process and not the easiest of tasks.

Joe W. Walker, Jr. MS, SCT(ASCP)
Anatomical Pathology Manager
joewal...@rrmc.org, www.rrmc.org

-Original Message-
From: Amy Self via Histonet 
Sent: Friday, August 16, 2019 2:48 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP Cancer protocols and synoptic reporting

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the sender.


Hi Histotechs and Happy Friday,

Would someone please share a Policy on the CAP Cancer Protocols and Synoptic 
Reporting?  How are you handling this process?

CAP Checklist questions - ANP.12350 Cancer Protocols and ANP.12385 Synoptic 
Reporting

Thank you for any help with this,
Amy


Amy Self
Histology Lab Senior Tech
Lab
Tidelands Georgetown Memorial Hospital
606 Black River Road
Georgetown, SC 29440
(843) 520-8711
as...@tidelandshealth.org
Our mission:  We help people live better lives through better health.


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Re: [Histonet] CAP Requirements for Scales and Balances

[Laurie Redmond via Histonet]

Yes, there are CAP requirements, and I believe they are in either the General 
checklist or the All Common checklist.  I think the requirement is for 
calibration once a year. 

Laurie Redmond


-Original Message-
From: Piche, Jessica via Histonet 
To: histonet@lists.utsouthwestern.edu 
Sent: Wed, Jun 19, 2019 11:15 am
Subject: [Histonet] CAP Requirements for Scales and Balances

Good Afternoon All,

Does anyone know if there are stated CAP requirements in regards to the 
calibration of scales and balances, and the intervals at which they should be 
calibrated?

Thanks in advance and have a good day!

Jessica Piche, HT (ASCP)
Waterbury Hospital
Waterbury, CT
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Re: [Histonet] Cap PAP Smears Controls

[Joe W. Walker, Jr. via Histonet]

HI Mary Ann,

If you are referring to the Pap stain for Pap tests or for Non-Gyn specimens 
including FNA, you will need to verify daily that the technical quality of the 
slides.  This evaluation should include any preparation for the day, including 
liquid based, cytospins, direct smears, and cell blocks.  The slides should be 
evaluated to ensure the presentation of the cells, including the staining 
characteristics are appropriate for the nuclei and cytoplasm of the cells in 
question.  In our lab, we evaluate a slide from each staining run.  If we run 
only Pap tests, then a slide is randomly pulled from the run and evaluated. For 
non-gyn specimens, we apply the same technique if those specimens types were 
run on any day.  For non-gyn specimens, we also evaluate the Romanowsky stained 
slides.

As a CAP inspector, I have also observed labs who utilize a buckle smear for 
direct smear preps and also for liquid based preps.  They will run them through 
the stains to ensure that they work as expected before staining patient 
specimens. I don't think there is one correct way to perform this evaluation 
but the key is to make sure that you are evaluating each type of prep and the 
stain that you perform in your lab each day.  

Joe W. Walker, Jr. MS, SCT(ASCP) 
Anatomical Pathology Manager
Rutland Regional Medical Center
160 Allen Street, Rutland, VT 05701
P 802.747.1790  F 802.747.6525
joewal...@rrmc.org, www.rrmc.org
Our Vision:
To be the Best Community Healthcare System in New England
Our Commitment to our Community: We Listen, We Respect, We Care . . . Always.
Joint Commission Accredited | Best Regional Hospital: U.S. News & World Report 
| Leapfrog Hospital Safety A Rating
ANCC Magnet Hospital Designation® | Healthgrades: Excellence Award for Patient 
Safety | Healthgrades: Outstanding Patient Experience Award

-Original Message-
From: Mary Ann via Histonet  
Sent: Monday, July 16, 2018 12:52 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] Cap PAP Smears Controls

Hello,

In preparing for CAP I have a question:
Does anyone run a positive PAP control with their run?

Sent from my iPhone

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Re: [Histonet] CAP control revision

[Terri Braud via Histonet]

For all stains, we report the control verification on the patient report when 
reporting the stain results, and we run negative tissue controls for our 
organism stains, AFB and GMS

Terri L. Braud, HT(ASCP)
Anatomic Pathology Supervisor
Laboratory
Holy Redeemer Hospital
1648 Huntingdon Pike
Meadowbrook, PA 19046
ph: 215-938-3689
fax: 215-938-3874
Care, Comfort, and Heal
 

  2. revised Cap regulation ANP .21395  ?? (Roy, Ryan)
Message: 2
Date: Thu, 14 Jun 2018 12:18:32 +
From: "Roy, Ryan" 
Subject: [Histonet] revised Cap regulation ANP .21395  ??
Hello Histonetters,
What is the take home message of this revision? How are other labs complying 
with respect to Special staining?  Do you keep records of individual case 
control verification or just individual block verification? Does anyone run NEG 
controls for Special staining? Is this regulation requiring Neg Controls for 
special stains? Any thoughts are appreciated.
" **revised** 08/17/2016
ANP .21395
Special Stains/Studies
For special stains, including histochemical stains, and studies using 
immunologic and ISH methodology, positive and negative controls are verified 
and recorded as acceptable prior to or concurrent with the reporting of patient 
results and records maintained. "

Thanks you,
Ryan Roy BS,  HTL (ASCP)CM
Laboratory: Histology Department
Manchester VA Medical Center
Manchester NH
603 -624-4366 extension 6640


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Re: [Histonet] CAP checklist ANP.11680 Cross Contamination

[Terri Braud via Histonet]

In response to the request to post the new phase II CAP requirement on cross 
contamination : 
**NEW**   08/21/2017
ANP.11680   Cross Contamination Phase II
There is a written procedure to prevent cross-contamination of specimens during 
grossing.
NOTE:  At a minimum, cleaning (e.g. wiping or rinsing) of forceps and scalpel 
blades between cases is required. In addition, if a laboratory processes both 
small specimens (e.g. biopsies) and large specimens (e.g. surgical resections), 
cleaning of instruments and cutting surfaces must be performed between cases. 
Avoid re-using cotton swabs/applicator sticks on multiple specimens or 
"double-dipping" the cotton swab/applicator in the ink. Some laboratories may 
choose to use disposable surfaces (e.g. formalin absorbent pads, butcher paper, 
etc.) for large cases. Grossing of similar types of specimens sequentially 
should be avoided, if feasible.
REFERENCES
1)  Lott R, et al. Practical Guide to Specimen Handling in Surgical 
Pathology. College of American Pathologists, November 2015. Available at 
http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution%20Folders/WebContent/pdf/practical-guide-specimen-handling.pdf,
 Accessed November 4, 2016.
2)  Gephardt GN, Zarbo RJ. Extraneous tissue in surgical pathology: A 
College of American Pathologists study of 275 laboratories. Arch Pathol Lab 
Med. 1996;120:1009-14

Terri L. Braud, HT(ASCP)
Anatomic Pathology Supervisor
Laboratory
Holy Redeemer Hospital
1648 Huntingdon Pike
Meadowbrook, PA 19046
ph: 215-938-3689
fax: 215-938-3874
Care, Comfort, and Heal
   2. Re: Cross Contamination CAP policy (Bob Richmond)

Message: 2
Date: Sat, 13 Jan 2018 14:32:45 -0500
From: Bob Richmond 
To: "Histonet@lists.utsouthwestern.edu"

Subject: Re: [Histonet] Cross Contamination CAP policy
Message-ID:

Content-Type: text/plain; charset="UTF-8"

Terri L. Braud, HT(ASCP), Anatomic Pathology Supervisor at Holy Redeemer 
Hospital in Meadowbrook PA notes:

>>Our policy calls for wiping of forceps with gauze between cases at 
>>gross
and at embedding. At gross, we use a disposable absorbent lined pad on the 
cutting board for each larger case, and just a fresh c-fold paper towel between 
small biopsy cases. We do not allow double-dipping of swabs into ink, but 
instead, pour out small amounts into a large plastic weigh boat which is also 
discarded after the case. We use disposable safety scalpels, with a 70 blade 
(love 'em) for each case. For excessively bloody/fatty cases, we put the dirty 
forceps into an enzyme pre-soak (Aseptizyme) to remove all tissue debris. Then 
they are scrubbed with a brush, then rinsed in a disinfectant before being 
re-used.<<

I've never seen a pathology service (and I've worked in 80 of them) do any of 
these things, all of them good ideas. I'm glad to see the CAP taking the issue 
up. Carry-overs from case to case are common, particularly when the grosser is 
overworked and working too fast. I've never seen a serious error made as a 
result of such contamination, but I've seen a few close calls.

Terri Braud, could you copy us the actual text in the CAP inspection form?

Bob Richmond
Samurai Pathologist
Maryville TN




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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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Re: [Histonet] CAP code for H

[Nina J. Rich via Histonet]

Thanks for information it was very helpful.  Happy Lab Week to all!!

From: Walter Benton 
Sent: Monday, April 24, 2017 12:09 PM
To: Nina J. Rich
Cc: histonet@lists.utsouthwestern.edu
Subject: RE: CAP code for H

Hope this helps.

ANP.10042 Histologic Prep Quality Phase I
There is a written procedure that describes the process by which pathologists 
or their
designees provide feedback to the histology laboratory on the quality of 
histologic
preparations. This procedure must include the daily recording of the quality of 
the
histologic preparations for each day of tissue processing and slide preparation.
NOTE: Histologic preparations refer to H & E sections, histochemical stains,
immunohistochemistry preparations, and in situ hybridization preparations.
This requirement applies to laboratories that process and interpret histologic 
preparations at the
same location, as well as laboratories that interpret histologic preparations 
processed at another
laboratory (regardless of that outside laboratory's accrediting organization).
Records of such feedback and corrective action taken when problems are 
identified may be
incorporated into the laboratory's quality management program.
Specific quality control requirements for special stains, immunohistochemistry, 
and other special
studies are found elsewhere in this checklist.
Evidence of Compliance:
✓ Records of feedback and corrective action for problems identified with 
histologic prep quality

ANP.11734 Slide Quality Phase II
Slides are of sufficient quality for diagnosis.
NOTE: Histopathology slides must be of adequate technical quality to be 
diagnostically useful.
Criteria to evaluate include adequate tissue fixation, processing, thickness of 
sections, absence
of interfering tissue folds and tears, and good staining technique and cover 
slipping. For
hematoxylin and eosin and other routine stains, the patient slide serves as the 
internal control to
ensure adequate staining technique. The sections must be cut from sufficient 
depth in the block
to include the entire tissue plane.

**REVISED** 07/28/2015
CYP.04300 Daily QC Phase II
There are records of daily review of the technical quality of cytologic 
preparations by the
pathologist or supervisory-level cytotechnologist.
NOTE: The technical quality of cytologic preparations must be checked daily (on 
days processing
occurs). This includes checking all stains for predicted staining 
characteristics each day of use.
This check must include all of the types of preparations seen that day such as 
cytospins, cell
blocks, and liquid based preparations.
If preparation and staining is performed by a different laboratory, there must 
be a procedure for
the laboratory performing the preparation and staining to verify the 
acceptability of the quality
of preparations and the acceptability of controls (if needed) before transfer. 
Records of this
verification must be readily available to the laboratory performing 
interpretations. There should
also be a mechanism for feedback from the interpreting laboratory to the 
laboratory that prepared
the slides of any issues with the preparations.


Walter Benton HT(ASCP)QIHC
Lab Operations Manager
Chesapeake Urology Associates
806 Landmark Drive, Suite 127
Glen Burnie, MD 21061
Chesapeakeurology.com

Voted a Best Place to Work by
Baltimore and Modern Healthcare
Magazines.


-Original Message-
From: Nina J. Rich via Histonet [mailto:histonet@lists.utsouthwestern.edu]
Sent: Monday, April 24, 2017 11:14 AM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP code for H

Does anyone know if CAP requires that labs run an H control daily? If so what 
is the # for that requirement?  Also, for pap stains?

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Re: [Histonet] CAP code for H

[Walter Benton via Histonet]

Hope this helps.

ANP.10042 Histologic Prep Quality Phase I
There is a written procedure that describes the process by which pathologists 
or their
designees provide feedback to the histology laboratory on the quality of 
histologic
preparations. This procedure must include the daily recording of the quality of 
the
histologic preparations for each day of tissue processing and slide preparation.
NOTE: Histologic preparations refer to H & E sections, histochemical stains,
immunohistochemistry preparations, and in situ hybridization preparations.
This requirement applies to laboratories that process and interpret histologic 
preparations at the
same location, as well as laboratories that interpret histologic preparations 
processed at another
laboratory (regardless of that outside laboratory's accrediting organization).
Records of such feedback and corrective action taken when problems are 
identified may be
incorporated into the laboratory's quality management program.
Specific quality control requirements for special stains, immunohistochemistry, 
and other special
studies are found elsewhere in this checklist.
Evidence of Compliance:
✓ Records of feedback and corrective action for problems identified with 
histologic prep quality

ANP.11734 Slide Quality Phase II
Slides are of sufficient quality for diagnosis.
NOTE: Histopathology slides must be of adequate technical quality to be 
diagnostically useful.
Criteria to evaluate include adequate tissue fixation, processing, thickness of 
sections, absence
of interfering tissue folds and tears, and good staining technique and cover 
slipping. For
hematoxylin and eosin and other routine stains, the patient slide serves as the 
internal control to
ensure adequate staining technique. The sections must be cut from sufficient 
depth in the block
to include the entire tissue plane.

**REVISED** 07/28/2015
CYP.04300 Daily QC Phase II
There are records of daily review of the technical quality of cytologic 
preparations by the
pathologist or supervisory-level cytotechnologist.
NOTE: The technical quality of cytologic preparations must be checked daily (on 
days processing
occurs). This includes checking all stains for predicted staining 
characteristics each day of use.
This check must include all of the types of preparations seen that day such as 
cytospins, cell
blocks, and liquid based preparations.
If preparation and staining is performed by a different laboratory, there must 
be a procedure for
the laboratory performing the preparation and staining to verify the 
acceptability of the quality
of preparations and the acceptability of controls (if needed) before transfer. 
Records of this
verification must be readily available to the laboratory performing 
interpretations. There should
also be a mechanism for feedback from the interpreting laboratory to the 
laboratory that prepared
the slides of any issues with the preparations.


Walter Benton HT(ASCP)QIHC
Lab Operations Manager
Chesapeake Urology Associates
806 Landmark Drive, Suite 127
Glen Burnie, MD 21061
Chesapeakeurology.com

Voted a Best Place to Work by
Baltimore and Modern Healthcare
Magazines.


-Original Message-
From: Nina J. Rich via Histonet [mailto:histonet@lists.utsouthwestern.edu]
Sent: Monday, April 24, 2017 11:14 AM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP code for H

Does anyone know if CAP requires that labs run an H control daily? If so what 
is the # for that requirement?  Also, for pap stains?

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Re: [Histonet] CAP checklist help

[Walter Benton via Histonet]

Leica sells a temperature verification kit that should meet your needs for CAP 
compliance and documentation. We use it for our Leica Thermobrites used in the 
processing of FISH.

-Original Message-
From: Charles Riley via Histonet [mailto:histonet@lists.utsouthwestern.edu]
Sent: Wednesday, December 28, 2016 11:55 AM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP checklist help

I need help with figuring out how to meet checklist # ANP.23420.   We use
the Leica Bond III and MAX  to do our ISH slides.  How do I test the 
temperature and how would you recommend recording the results?

--

Charles Riley HT(ASCP)CM

Histopathology Coordinator/ Mohs
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Re: [Histonet] CAP checklist help

[Eddie Martin via Histonet]

Hi Charles,

The Leica BOND system displays the temperatures of the individual heating pads 
during the retrieval stage on your computer monitor. You can easily take a 
screenshot of your computer monitor and save it to a flash drive as a digital 
record.
*A heating error would appear if the individual heating pad didn't reach 100 
degrees. 

 The Leica service engineer for the Bond can also provide documentation every 
time they service your IHC analyzer. You can also check your slide staining 
history and find cases that didn't stain well and individually check if the 
result was due to the temperature not reaching 100 degrees on that individual 
heating pad. Hope this helps. 

V/r,
Eddie Martin, HTL, QIHC
IHC Histotechnologist III
Walter Reed National Military Medical Center 


> On Dec 28, 2016, at 11:55 AM, Charles Riley  wrote:
> 
> I need help with figuring out how to meet checklist # ANP.23420.   We use
> the Leica Bond III and MAX  to do our ISH slides.  How do I test the
> temperature and how would you recommend recording the results?
> 
> -- 
> 
> Charles Riley HT(ASCP)CM
> 
> Histopathology Coordinator/ Mohs
> 

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Re: [Histonet] CAP ANP.22970 Query

[Cartun, Richard via Histonet]

Do you participate in the CAP's PT program for ER/PR and HER2 IHC testing?  If 
so, you can have all your pathologists who interpret ER/PR/HER2 IHC testing 
score the PT TMAs, complete the worksheets, and then you can establish their 
interobserver variability.  If not, pull 20 cases where ER/PR/HER2 was 
performed, prepare a score-sheet and have all your pathologists interpret these 
20 cases.  Run the same comparison.  You will see ER positivity in the range of 
75-90%, PR positivity in the range of 60-75%, and HER2 should be between 
10-20%.  Obviously, these ranges will depend on your patient demographics, and 
the antibody clones and IHC detection used.

Richard

Richard W. Cartun, MS, PhD
Director, Histology & The Martin M. Berman, MD Immunopathology & Morphologic 
Proteomics Laboratory
Director, Biospecimen Collection Programs
Assistant Director, Anatomic Pathology
Hartford Hospital
80 Seymour Street
Hartford, CT  06102
(860) 972-1596
(860) 545-2204 Fax

-Original Message-
From: Joanne Clark via Histonet [mailto:histonet@lists.utsouthwestern.edu]
Sent: Monday, August 22, 2016 4:05 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP ANP.22970 Query

Hi Histonetters, we are wondering what everyone else out there is doing to be 
compliant with the following requirement?  We do ER and PR by IHC  but dont 
know what published benchmarks are out there to compare ourselves to.  Also, 
how do you record interobserver variability amongst the pathologists?  Any 
insights into this would be appreciated.



ANP.22970 Annual Result Comparison Phase II For immunohistochemical and 
FISH/ISH tests that provide independent predictive information, the laboratory 
at least annually compares its patient results with published benchmarks, and 
evaluates interobserver variability among the pathologists in the laboratory.
NOTE: Individuals interpreting the assay must also have their concordance 
compared with each other and this concordance should also be at least 95%.
With specific reference to estrogen and progesterone receptor studies: in 
general, the overall proportion of ER-negative breast cancers (invasive and 
DCIS) should not exceed 30%. The proportion is somewhat lower in postmenopausal 
than premenopausal women (approximately 20% vs. 35%). The proportion is 
considerably lower in well-differentiated carcinomas (<10%) and certain special 
types of invasive carcinomas (<10% in lobular, tubular, and mucinous types).
The proportion of PgR-negative cases is 10-15% higher than for ER-negative in 
each of these settings. Investigation is warranted if the proportion of 
negative cases is significantly lower in any of these settings.

Joanne Clark, HT
Director of Histology
Pathology Consultants of New Mexico
Roswell, New Mexico




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Re: [Histonet] CAP

[Elizabeth Chlipala via Histonet]

Bernice

We are not a clinical lab, we are a GLP compliant lab and we have a procedure 
that addresses this and everything else about reagent preparation.  I will put 
the procedure and forms that we use on the NSH BLOCK for anyone who is 
interested.

Liz

Elizabeth A. Chlipala, BS, HTL(ASCP)QIHC
Premier Laboratory, LLC
PO Box 18592
Boulder, CO 80308
(303) 682-3949 office
(303) 682-9060 fax
(303) 881-0763 cell
l...@premierlab.com
www.premierlab.com

Ship to Address:

Premier Laboratory, LLC
1567 Skyway Drive, Unit E
Longmont, CO 80504

-Original Message-
From: Bernice Frederick via Histonet [mailto:histonet@lists.utsouthwestern.edu] 
Sent: Friday, February 26, 2016 6:57 AM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP

ANP21382. What kind of policy or SOP do you all have for this question? T asks 
how reagents are given an expiration. This includes but is not restricted to 
reagents where manufacturer does not specify a date. We date made up reagents 
as a 6 month expiration unless we know it doesn't last that long. Came up 
during interim self inspection.
Thanks,
Bernice

Bernice Frederick HTL (ASCP)
Senior Research Tech
Pathology Core Facility
Robert. H. Lurie Cancer Center
Northwestern University
710 N Fairbanks Court
Olson 8-421
Chicago,IL 60611
312-503-3723
b-freder...@northwestern.edu

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Re: [Histonet] CAP Checklist Question

[Bob Richmond via Histonet]

Amy Self, Histology Lab Senior Tech, Tidelands Georgetown Memorial Hospital
in Georgetown SC asks: >>I am going through the CAP checklist and was
wondering how the following question below is being handled by everyone
that gets inspected by CAP.
ANP.12360 Report Completeness: Surgical pathology reports for specimens
with malignant  diagnosis from definitive cancer resections are outlined in
the CAP Cancer Protocols are audited annually to ensure that all required
elements are included.<<

Your hospital should have some sort of cancer registry that's doing this,
and your pathologist probably gets occasional requests to amplify reports.
Ask your pathologists about this.

Do you have an anatomic pathology application that generates CAP templates
automatically? There are a number of these, such as mTuitive, which I've
used successfully.

Bob Richmond
Samurai Pathologist
Maryville TN
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Re: [Histonet] CAP checklikst for pathology lab

[Whitaker, Bonnie]

The checklists are now customized, and your version must be downloaded from 
CAP.org.

Good luck!

Bonnie



Sent with Good (www.good.com)


-Original Message-
From: Пешков Максим [maxim...@mail.rumailto:maxim...@mail.ru]
Sent: Monday, June 29, 2015 11:43 PM Eastern Standard Time
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP checklikst for pathology lab


Dear histonetters, can you send me, pleasse, the last pdf version cap checklist 
for pathology lab? Or reference where I can download it.
Sincerely,
Maxim Peshkov,
Russia,
Taganrog.
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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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RE: [Histonet] CAP Survey Question

[joelle weaver]

I agree. It is required here on everything. 




Joelle Weaver MAOM, HTL (ASCP) QIHC
 
Date: Thu, 5 Dec 2013 17:50:47 -0500
From: amosbro...@gmail.com
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP Survey Question

Hi,
Regarding the question of weather it would save time to not have the techs 
QC check the IHC slides. I feel that it would be an extremely bad practice to 
omit the techs from the QC process. This goes for not only IHC but special 
stains and even HE stains. It is imperative that the techs know what the 
slides they are submitting look like. It is possible for even a lowly tech to 
spot a problem before passing the slide on to a pathologist. And even 
pathologists are capable of missing something from time to time. This also 
educates the tech so that when a pathologist has a question about a stain he is 
not met with a blank stare. So CAP requirement or not it should be done anyway.
 
Just my opinion,
(But I'm right),
Amos

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RE: [Histonet] CAP Survey Question

[Piche, Jessica]

More viewing with the  pathologist would be great!

Jessica Piche, HT(ASCP)

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of joelle weaver
Sent: Friday, December 06, 2013 8:07 AM
To: Amos Brooks; histonet@lists.utsouthwestern.edu
Subject: RE: [Histonet] CAP Survey Question

Looking at each slide ( at least controls) is required here, period, for 
everything. I do not see how  sending out stains that didn't work  and the 
rework and would save time? Maybe I missed some point in the thread?
I don't see how you could learn without this QC practice, even better if you 
can review under the microscope with a pathologist.




Joelle Weaver MAOM, HTL (ASCP) QIHC

From: joellewea...@hotmail.com
To: amosbro...@gmail.com; histonet@lists.utsouthwestern.edu
Subject: RE: [Histonet] CAP Survey Question
Date: Fri, 6 Dec 2013 13:04:01 +




I agree. It is required here on everything.




Joelle Weaver MAOM, HTL (ASCP) QIHC

Date: Thu, 5 Dec 2013 17:50:47 -0500
From: amosbro...@gmail.com
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP Survey Question

Hi,
Regarding the question of weather it would save time to not have the techs 
QC check the IHC slides. I feel that it would be an extremely bad practice to 
omit the techs from the QC process. This goes for not only IHC but special 
stains and even HE stains. It is imperative that the techs know what the 
slides they are submitting look like. It is possible for even a lowly tech to 
spot a problem before passing the slide on to a pathologist. And even 
pathologists are capable of missing something from time to time. This also 
educates the tech so that when a pathologist has a question about a stain he is 
not met with a blank stare. So CAP requirement or not it should be done anyway.

Just my opinion,
(But I'm right),
Amos

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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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RE: [Histonet] CAP guideline for fixation time

[Ellenburg, Deborah]

We have a label that we place on the original requisition documenting
the time the specimen was placed in formalin and the time it came out of
formalin(changed stations on tissue processor).  When the
transcriptionist 
transcribe the gross dictation they give the total number of hours the
specimen was in formalin.  The pathologist is able to see the total time
in formalin when reviewing their working draft.



-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Victor
A. Tobias
Sent: Friday, January 04, 2013 6:21 PM
To: 'histonet'
Subject: [Histonet] CAP guideline for fixation time

Per CAP guideline, in our reports of predictive markers(ER/PR/Her2),
Pathologists need to check that the total fixation time of specimens is
within the CAP guideline. Is this information readily available to the
pathologists at the time of writing the report? How are others
documenting this?

Have a great weekend.

Victor

Victor Tobias HT(ASCP)
Clinical Applications Analyst
Harborview Medical Center
Dept of Pathology Room NJB244
Seattle, WA 98104
vtob...@u.washington.edumailto:vtob...@u.washington.edu
206-744-2735
206-744-8240 Fax
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RE: [Histonet] CAP New requirement: Cytopathology Exclusions from Submissions

[Ian R Bernard]

Yes, This is a new checklist item as of 07/11/2011. Cytopathology Exclusion 
question: CYP.01650.

Ian
-Original Message-
From: Oscar [mailto:omgwake...@gmail.com] 
Sent: Sunday, December 30, 2012 9:15 PM
To: Ian R Bernard
Subject: Re: [Histonet] CAP New requirement: Cytopathology Exclusions from 
Submissions

Hi Neha. I was checking the Histonet, and found the question below.  Is there a 
requirement for non-GYN specimens? There is one for Histo, but didn't know 
there was a Cyto...

Sent from my iPad2


On Dec 30, 2012, at 10:01 PM, Ian R Bernard ibern...@uab.edu wrote:

 Fellow Laboratorians who process Cytopathology specimens, specifically, 
 Non-Gyn specimens. A policy that list specimens that are excluded from 
 routine submission to cytology for processing.  
 
 Please share your facilities' approved examples on the types of specimens, 
 and a justification and reference as to why this should be excluded.
 
 Thanks
 Ian
 Colorado
 
 
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RE: [Histonet] CAP and negative IHC controls

[Debra Siena]

It is my understanding that you still need a negative tissue control but if 
using a polymer detection kit that you may stop doing a negative reagent 
control.  The negative tissue control is a tissue known to not contain the 
antigen in the tissue, it can be an internal control, or a separate control but 
if internal control, then it must be designated as to how it will be used in 
your procedure manual.  Hope that helps.

Debbie Siena
800.442.3573 ext. 229 | www.statlab.com


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of 
jsjurc...@comcast.net
Sent: Friday, December 28, 2012 2:19 PM
To: .
Subject: [Histonet] CAP and negative IHC controls

How is everyone interpreting the CAP rule about using negative controls? Do we 
still need a negative with each patient slide? 
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Re: [Histonet] CAP and negative IHC controls

[Richard Cartun]

That decision needs to be made by your Medical Director.  In my laboratory we 
use polymer detection for almost all of our IHCs and, therefore, I don't 
require a Negative Reagent Control for those cases.  We have one antibody 
that requires avidin-biotin detection and we run a negative reagent control in 
parallel whenever we run that antibody.  In my experience, if you are using 
polymer detection and your antibodies are properly optimized and validated, the 
negative reagent control slide serves no useful purpose and, therefore, is not 
needed.

Best wishes to everyone on Histonet for the coming New Year!

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
(860) 545-2204 Fax


 jsjurc...@comcast.net 12/28/2012 3:18 PM 
How is everyone interpreting the CAP rule about using negative controls? Do we 
still need a negative with each patient slide? 
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Re: [Histonet] CAP GEN. 41770 Residual Detergent on Glassware

[Geoff]

Over the years I have heard about some folks obsessing (my opinion) 
about this.
I have never had a problem and I  don't think it is an issue, assuming 
one rinses the glassware thoroughly.
If the glass is clean water does not bead but sheets off. I only used 
distilled water for silver stains, making osmium for EM, etc.

Look up 'water break test' and see if you can find anything helpful.

Geoff

On 10/12/2012 11:40 AM, Valerie O'Connor wrote:

Hi All,
I process and stain GI biopsies only. I use do a basic HE, Diff Quick for 
H.pylori, PAS for candida , Trichrome, and Alcian Blue/PAS.
Is anyone aware of documentation stating that residual detergent on glassware 
would have a deleterious affect on the quality of the
stains mentioned above. I cannot find anything.
Thanks in advance,

Valerie O'Connor B.S. HT (ASCP)
Gastroenterology Center of CT.
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--
--
**
Geoff McAuliffe, Ph.D.
Neuroscience and Cell Biology
Robert Wood Johnson Medical School
675 Hoes Lane, Piscataway, NJ 08854
voice: (732)-235-4583; fax: -4029
mcaul...@umdnj.edu
**



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Re: [Histonet] CAP education requirements for grossing

[Kim Donadio]

Unless its changed from CAP 2011 checklist and I didnt hear about it. Grossing 
is considered high complexity, so the guidelines are the same for anyone doing 
high complexity testing. They would need documented training as do any other 
high comlexity task.
 
here is what CAP 2011 says about it.
 **REVISED** 07/11/2011ANP.11610 Gross Examination Qualifications Phase IIIf 
individuals other than a pathologist or pathology resident assist in gross 
examinations,
such individuals qualify as high complexity testing personnel under CLIA 
regulations.NOTE: The laboratory director may delegate the dissection of 
specimens to non-pathologist
individuals; these individuals must be qualified as high complexity testing 
personnel under CLIA
regulations. The minimum training/experience required of such personnel is:
1. An earned associate degree in a laboratory science or medical laboratory 
technology,
obtained from an accredited institution, OR
2. Education/training equivalent to the above that includes at least 60 
semester hours or
equivalent from an accredited institution. This education must include 24 
semester
hours of medical laboratory technology courses, OR 24 semester hours of science
courses that includes 6 semester hours of chemistry, 6 semester hours of 
biology, and
12 semester hours of chemistry, biology or medical laboratory technology in any
combination. In addition, the individual must have laboratory training 
including either
completion of a clinical laboratory training program approved or accredited by 
the
ABHES, NAACLA, or other organization approved by HHS (note that this training 
may
be included in the 60 semester hours listed above), OR at least 3 months 
documented
laboratory training in each specialty in which the individual performs high 
complexity
testing.
It is the responsibility of the laboratory director to determine whether an 
individual's education,
training and experience satisfies the requirements of this checklist 
requirement.
This checklist requirement applies only to laboratories subject to US 
regulations.Evidence of Compliance:✓ Records of qualifications including degree 
or transcript and work history in related field ORdocumentation of 
grandfathered exceptionREFERENCES
1) 
of 1988; final rule. Department of Health and Human Services, Centers for 
Medicare and Medicaid Services. Clinical laboratory improvement amendmentsFed 
Register. 2003(Oct 1):1070-1071 [42CFR493.1489], 1071-1072 
[42CFR493.1491]ANP.11640 Performance Evaluation Phase IIThe performance of 
non-pathologist(s) who assist in the performance of gross tissue
examinations is evaluated by the pathologist on a regular, periodic 
basis.Evidence of Compliance:✓ Written procedure and schedule for evaluating 
performance of non-pathologists AND✓ Records of evaluation documented at 
defined frequencyREFERENCES
1) Cibull ML. QA. Northfield, IL: College of American Pathologists CAP Today. 
1997;11(7):1122) Grzybicki DM, et al. The usefulness of pathologists' 
assistants. Am J Clin Pathol. 1999;112:619-626
 



From: Pam Barker rel...@earthlink.net
To: Histonet histonet@lists.utsouthwestern.edu 
Sent: Tuesday, August 14, 2012 9:59 AM
Subject: [Histonet] CAP education requirements for grossing

Hi Fellow Histonetters!!
I hope everyone is having a great day!!  I have a quick question from a
client that I hope someone can give me a definitive answer on.  What are the
education requirements for grossing under CAP as opposed to CLIA.  I was
told that for CAP a B.S. degree is required and I wanted to check and see if
anyone knew if that was the case.  I know CLIA is an A. S. Degree or a
certain number of hours in biology.  Does CAP require a bachelor's of
science?  Thanks-Pam  

Thank You!
  

Pam Barker
President/Senior Recruiting Specialist-Histology
RELIA Solutions
Specialists in Allied Healthcare Recruiting
5703 Red Bug Lake Road #330
Winter Springs, FL 32708-4969
Phone: (407)657-2027
Cell:    (407)353-5070
FAX:    (407)678-2788
E-mail: rel...@earthlink.net 
http://www.facebook.com/ http://www.facebook.com/PamBarkerRELIA 
/PamBarkerRELIA
www.linkedin.com/in/reliasolutions
www.twitter.com/pamatrelia 


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RE: [Histonet] CAP autopsy requirement?

[Victor A. Tobias]

If it's true, I hope our director doesn't share the information. We got the 60 
day thing down pat and all of our TAT reports. Hate to see it all go to waste.

Victor Tobias HT(ASCP)
Clinical Applications Analyst
Harborview Medical Center
Dept of Pathology Room NJB244
Seattle, WA 98104
vtob...@u.washington.edu
206-744-2735
206-744-8240 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.

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of mtitf...@aol.com
Sent: Thursday, August 09, 2012 12:14 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP autopsy requirement?


Am I hearing right? The CAP has done away with the requirement to sign out 
autopsies within 60 days? (But you still have to get the PAD out in two days)? 
How will I ever get pathologists motivated any more?!

Michael Titford
Pathology
USA Mobile AL

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RE: [Histonet] CAP autopsy requirement?

[Rathborne, Toni]

90% of the cases need to be signed out in 60 days, not all cases.

**NEW** 07/31/2012
ANP.33120 Final Report TAT Phase II
The final autopsy report is produced within 60 working days in 90% of the cases.
NOTE: The 90% threshold is used in recognition of the fact that occasional 
unusual cases may
require more than 60 days for completion, particularly when external 
consultation is required. If
cases exceed 60 days, there should be documentation of the reason for the delay 
and of ongoing
review of this information by the director of the service.
Evidence of Compliance:
✓ Review of turnaround time data for the final autopsy report
REFERENCES
1) Adickes ED, Sims KL. Enhancing autopsy performance and reporting. A system 
for a 5-day completion time. Arch Pathol Lab Med.
1996;120:249-253
2) Smith MT, Garvin AJ. Anatomic pathology turnaround times. Use and abuse. Am 
J Clin Pathol 1996;106(Suppl 1):S70-S73
3) Baker PB, et al. Quality assurance of autopsy face sheet reporting, final 
autopsy report turnaround time, and autopsy rates. A College
of American Pathologists Q-Probes study of 10 003 autopsies from 418 
institutions. Arch Pathol Lab Med. 1996;120:1003-1008
4) Hanzlick RL. The autopsy lexicon. Suggested headings for the autopsy report. 
Arch Pathol Lab Med. 2000;124:594-603
5) Bove KE, et al. The role of the autopsy in medical malpractice cases, II. 
Controversy related to autopsy performance and reporting.
Arch Pathol Lab Med. 2002;126:1032-1035
6) Hutchins GM, et al. Autopsy reporting. In: Collins KA, et al, eds. Autopsy 
Performance and Reporting. 2nd ed. Northfield, IL: College
of American Pathologists: 2003; chap 28
7) Baker PB. Communication of autopsy results. In: Collins KA, et al, eds. 
Autopsy Performance and Reporting. 2nd ed. Northfield, IL:
College of American Pathologists: 2003; chap 33
**

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Victor A. Tobias
Sent: Thursday, August 09, 2012 3:49 PM
To: 'mtitf...@aol.com'; 'histonet@lists.utsouthwestern.edu'
Subject: RE: [Histonet] CAP autopsy requirement?

If it's true, I hope our director doesn't share the information. We got the 60 
day thing down pat and all of our TAT reports. Hate to see it all go to waste.

Victor Tobias HT(ASCP)
Clinical Applications Analyst
Harborview Medical Center
Dept of Pathology Room NJB244
Seattle, WA 98104
vtob...@u.washington.edu
206-744-2735
206-744-8240 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.

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of mtitf...@aol.com
Sent: Thursday, August 09, 2012 12:14 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP autopsy requirement?


Am I hearing right? The CAP has done away with the requirement to sign out 
autopsies within 60 days? (But you still have to get the PAD out in two days)? 
How will I ever get pathologists motivated any more?!

Michael Titford
Pathology
USA Mobile AL

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RE: [Histonet] CAP

[Stacy McLaughlin]

I looked at the message before I looked at the sender and thought they
were in my facility!  (our window is open too)
Pulse returning to normal.

Stacy McLaughlin, HT(ASCP)
Histology Supervisor
Cooley Dickinson Hospital
30 Locust Street
Northampton, MA 01060
(413)582-2019
stacy_mclaugh...@cooley-dickinson.org

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Bernice
Frederick
Sent: Wednesday, May 30, 2012 10:16 AM
To: Fellow HistoNetters
Subject: [Histonet] CAP

They're here!

Bernice Frederick HTL (ASCP)
Senior Research Tech
Pathology Core Facility
ECOGPCO-RL
Robert. H. Lurie Cancer Center
Northwestern University
710 N Fairbanks Court
Olson 8-421
Chicago,IL 60611
312-503-3723
b-freder...@northwestern.edumailto:b-freder...@northwestern.edu

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Re: [Histonet] CAP inspection requirements

[Kim Donadio]

CAP inspectors are your peers. In other words they are people managing other 
labs. So those people have a variety of degrees or experiences. They don't get 
paid to inspect. It's a requirement that labs that participate in CAP bi 
annually inspect another lab because CAP works as a peer review system. I'm 
sure there are actual paid jobs with CAP but best to look at Their website for 
those opportunity for job descriptions. Hope this helps. 
Kim D 

Sent from my iPhone

On May 2, 2012, at 5:58 AM, Mandy O'Connor ama...@ypii.com wrote:

 What are the requirements to become a CAP inspector?  Do you have to at least 
 be an actual registered HT/HTL?  Is just having a 2 year histotech degree 
 enough?
 
 Thanks,
 Mandy O'Connor, HTL (ASCP)
 Yellowstone Pathology Instit.
 Billings, MT
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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 approved shelf life of dyes solutions

[Rene J Buesa]

Such a list does not exist because the shelf life of every reagent (either dry 
or in solution) is determined by the manufacturer depending on their own 
specifications or desired turn-over buying/replenishing rate.
René J.

--- On Wed, 2/29/12, Sharon Allen sal...@dsmanitoba.ca wrote:


From: Sharon Allen sal...@dsmanitoba.ca
Subject: [Histonet] CAP approved shelf life of dyes  solutions
To: histonet@lists.utsouthwestern.edu
Date: Wednesday, February 29, 2012, 11:20 AM


Hi everyone,

Does anyone have a list of the shelf life of solutions, chemicals etc.
used in Histo staining methods that is acceptable for CAP accreditation
 would share the information?

We are trying to get a list together but different sources often
conflict. I would appreciate any information.

Thanks

Sharon Allen

Senior Medical Technologist

Neuropathology Lab-MS435U

Health Sciences Centre

820 Sherbrook Street

Winnipeg,MB, CA 

R3A 1R9

e-mail: sal...@dsmanitoba.ca




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Re: [Histonet] CAP GEN.41770 Glassware cleaning

[Rene J Buesa]

Using a pH meter requires that you add dist. water to the glass flask, swirl it 
around and hope that something will be trapped by that water that will give 
you an idea of the residual pH that may be in the glass.
Both things are quite improbable.
Instead of the pH meter or the paper indicator I always added to the water from 
the flask 
few drops of bromothymol blue that would turn yellow at pH7 and blue at pH7
On the other hand if the glass is properly washed in distilled water you will 
never get a pH other than neutral.
René J.
 
 
 

--- On Wed, 9/14/11, Clare Thornton cthorn...@dahlchase.com wrote:


From: Clare Thornton cthorn...@dahlchase.com
Subject: [Histonet] CAP GEN.41770 Glassware cleaning
To: 'Histonet@lists.utsouthwestern.edu' Histonet@lists.utsouthwestern.edu
Date: Wednesday, September 14, 2011, 4:07 PM


This checklist question has a sample procedure for how to check for residual 
detergent in glassware.  The procedure says to use a pH meter.  We've always 
used pH paper.  However, in reading their recommended procedure, you need to 
look for a change of greater than 0.2 pH units between source water and 
glassware pH.  Does anyone else use pH paper vs. a pH meter?  We only use our 
pH meter very infrequently and will calibrate it just prior to use.  If we use 
it for glassware cleaning, we'll have to calibrate more regularly, something 
I'd just as soon avoid if possible.  We've never had a problem with our 
glassware cleaning procedure with CAP in the past.  Any advice?

Clare J. Thornton, HTL(ASCP), QIHC
Assistant Histology Supervisor
Dahl-Chase Diagnostic Services
417 State Street, Suite 540
Bangor, ME 04401
cthorn...@dahlchase.com

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RE: [Histonet] cap new ANP.22760

[Settembre, Dana]

ANTIBODY LOTS
I have a Dako and I have a Bond too.
For the Dako I use my positive control. I use 3 slides.
One is treated as the negative control - no antibody
One is treated with the current lot 
One is treated with the new lot.
I keep all QC slides together.
I keep the 3 slides together.

For my Bond,
I use 2 slides of my positive control
When a new lot comes in I run the new lot and the negative control.
Then I compare them to the previous lot that I ran in the past.
I keep the slides in chronological order - the previous lot goes back with
The slides from that date. The NEW Lot slides get filed with today's date.

DETECTION SYSTEM LOTS
For the Bond I QC the detection kit using an antibody like Ki-67, it works well 
and always shows good nuclear staining.
I indicate the received date, and QC date.
I run the QC on my Ki-67 positive control.  I use 2 slides.
One is treated as the negative control - no antibody.
One is treated with Ki-67.
I compare these to the previous Detection kit QC slides

I created a written procedures for all of the above.

Hope this helps.

Dana Settembre
Immunohistochemistry Lab
University Hospital - UMDNJ
Newark, NJ

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of anita dudley
Sent: Friday, April 29, 2011 12:30 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] cap new ANP.22760


hi everyone,  just wondering how others were handling this checklist statement? 
 thanks so much for your input.  seems 
like a lot of extra work when running control with each show if each is working.
 
anita dudley
providence hosp
mobile alabama
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RE: [Histonet] CAP checklist, question ANP.23041.

[Mark Turner]

Just to clear the record, I do qualify for high-complexity testing,  My
doctorate is in another field, and I am very proud of my accomplishments
in both areas of interest.

Thanks for all the private emails and constructive remarks regarding
this question.  They have been very helpful. The consensus seems to be
that there is no consensus 

Mark Turner, HT(ASCP) QIHC

-Original Message-
From: Horn, Hazel V [mailto:hor...@archildrens.org] 
Sent: Thursday, March 17, 2011 3:23 PM
To: 'Mark Tarango'; Mark Turner
Cc: histonet@lists.utsouthwestern.edu
Subject: RE: [Histonet] CAP checklist, question ANP.23041.

A bit catty?

Hazel Horn
Hazel Horn, HT/HTL (ASCP)
Supervisor of Autopsy/Histology/Transcription
Arkansas Children's Hospital
1 Children's WaySlot 820
Little Rock, AR   72202

phone   501.364.4240
fax501.364.3155

visit us on the web at:www.archildrens.org

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Mark
Tarango
Sent: Wednesday, March 16, 2011 8:03 PM
To: Mark Turner
Cc: histonet@lists.utsouthwestern.edu
Subject: Re: [Histonet] CAP checklist, question ANP.23041.

Well I wouldn't try and use a Ph.D. in religous studies to qualify for
high
complexity testing...

On Wed, Mar 16, 2011 at 4:36 PM, Mark Turner
mtur...@csilaboratories.comwrote:

 Regarding CAP checklist, question ANP.23041.  The operation of the
imaging
 system is performed by high-complexity testing personnel.



 We have a question regarding the qualifications of the operators.  The
 operators of the Aperio system are simply scanning entire slides to
make a
 record for us prior to returning slides to the client.  Our operators
make
 no evaluation of the image other than whether the scan is adequate for
 recording purposes, and this is verified by our medical staff prior to
 release of the materials.  In your opinion, does this constitute
 high-complexity testing and require CLIA compliant qualifications for
the
 operators?

 Mark Turner, Ph.D, HT(ASCP) QIHC

 IHC / Histology Manager

 CSI Laboratories



 770-817-0817 x 394

 678-205-4669  FAX

 mtur...@csilaboratories.com mailto:nmon...@csilaboratories.com

 csilaboratories.com 

https://csi-srv-007/exchweb/bin/redir.asp?URL=http://www.csi-labs.com/

 11525 Park Woods Circle

 Alpharetta, GA 30005



 Important Warning: This e-mail is intended for the use of the person
to
 whom it is addressed and may contain information that is privileged
and
 confidential, the disclosure of which is governed by applicable law.
If the
 reader of this e-mail is not the intended recipient, or the employee
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RE: [Histonet] CAP checklist, question ANP.23041.

[Jesus Ellin]

Mark this is a new question and let me answer this for you from a
inspection point of view.  Currently there are 15 to 18 new questions
that deal with predicative markers and the digital images, most of these
are QA/QC related.  But the issue with images is that your people are
inspecting them.  When you are looking at an image it is more than just
click and go.  There are technical issues of Tiling, focus with z
stacking, AOI ( if the full image was captured), magnification, etc.
This is just technical to images, but then there are the aspects that
are to the histology world as in staining components, microtomy,
fixation, etc.  To say that they don't make a decision is a huge
understatement.  As far as I know CAP put this in because people were
just scanning images and sending them off.  There are also issues were
the scanner scans for possible algorithm studies.  You have to make sure
this is inline.  So as for the High complexity testing to what CLIA
defines, that is a back and forth issue.  Currently within our facility
you have to be licensed HT/HTL to do scanning.  This comes in line with
the CAP looking at creating a QM program and having the
technician/Technologist maintain competencies and assessments for this
technology.  There is also a competency and assessment due for the
pathologist as well for this technology.  I can go on and on, but you
can contact me off line for this.

Jesus Ellin
Yuma Regional Medical Center
928-336-1743

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Mark
Turner
Sent: Wednesday, March 16, 2011 4:36 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP checklist, question ANP.23041.

Regarding CAP checklist, question ANP.23041.  The operation of the
imaging system is performed by high-complexity testing personnel.

 

We have a question regarding the qualifications of the operators.  The
operators of the Aperio system are simply scanning entire slides to make
a record for us prior to returning slides to the client.  Our operators
make no evaluation of the image other than whether the scan is adequate
for recording purposes, and this is verified by our medical staff prior
to release of the materials.  In your opinion, does this constitute
high-complexity testing and require CLIA compliant qualifications for
the operators?

Mark Turner, Ph.D, HT(ASCP) QIHC

IHC / Histology Manager

CSI Laboratories

 

770-817-0817 x 394  

678-205-4669  FAX

mtur...@csilaboratories.com mailto:nmon...@csilaboratories.com 

csilaboratories.com
https://csi-srv-007/exchweb/bin/redir.asp?URL=http://www.csi-labs.com/


11525 Park Woods Circle

Alpharetta, GA 30005

 

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Re: [Histonet] CAP checklist, question ANP.23041.

[Mark Tarango]

Well I wouldn't try and use a Ph.D. in religous studies to qualify for high
complexity testing...

On Wed, Mar 16, 2011 at 4:36 PM, Mark Turner mtur...@csilaboratories.comwrote:

 Regarding CAP checklist, question ANP.23041.  The operation of the imaging
 system is performed by high-complexity testing personnel.



 We have a question regarding the qualifications of the operators.  The
 operators of the Aperio system are simply scanning entire slides to make a
 record for us prior to returning slides to the client.  Our operators make
 no evaluation of the image other than whether the scan is adequate for
 recording purposes, and this is verified by our medical staff prior to
 release of the materials.  In your opinion, does this constitute
 high-complexity testing and require CLIA compliant qualifications for the
 operators?

 Mark Turner, Ph.D, HT(ASCP) QIHC

 IHC / Histology Manager

 CSI Laboratories



 770-817-0817 x 394

 678-205-4669  FAX

 mtur...@csilaboratories.com mailto:nmon...@csilaboratories.com

 csilaboratories.com 
 https://csi-srv-007/exchweb/bin/redir.asp?URL=http://www.csi-labs.com/

 11525 Park Woods Circle

 Alpharetta, GA 30005



 Important Warning: This e-mail is intended for the use of the person to
 whom it is addressed and may contain information that is privileged and
 confidential, the disclosure of which is governed by applicable law. If the
 reader of this e-mail is not the intended recipient, or the employee or
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RE: [Histonet] CAP

[Alminde, Lea S]

How are you all responding to the Document Control Question  and do you have a 
sample you can share? Thanks

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Angela Bitting
Sent: Wednesday, February 23, 2011 2:51 PM
To: histonet; Akemi Allison; Jesus Ellin
Subject: Re: [Histonet] CAP

I did notice CAP inspectors concentrated more on safety this time around.

 Akemi Allison akemiat3...@yahoo.com 2/23/2011 11:50 AM 
We were given the new CAP checklist.  I totally revamped our SOP Manuals, ALL 
QC forms, etc. to comply.


This is the 1st Childrens Hospital CAP inspection I have undergone.  We are
inspected by other Children Hospital inspecting teams.


After all the hard work, they did not go through any of our SOP's, QC manuals,
Special Stains, validation protocols manuals for either histology or the IHC
lab.  Very odd indeed.


They spoke with the AP manager for our department only, except to ask one of the
histology techs how we disposed of our hazardous waste. Stay tuned till after
the summation.
Akemi Allison BS, HT(ASCP)HTL








From: Jesus Ellin jel...@yumaregional.org
To: Akemi Allison akemiat3...@yahoo.com; histonet
histonet@lists.utsouthwestern.edu
Sent: Wed, February 23, 2011 7:23:43 AM
Subject: RE: [Histonet] CAP

Akemi, were you inspected with the new CAP checklist or the old one?
The situation in our lab is that we were given the checklist and then
they changed us to the new format.  Your thoughts

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Akemi
Allison
Sent: Wednesday, February 23, 2011 7:03 AM
To: histonet
Subject: [Histonet] CAP

Lot's of Labs in LA are in their CAP window!  We had our CAP inspection
yesterday and having our summation this morning at 9:00.  I think our
department
did pretty good.  Keeping my fingers crossed.
Akemi Allison BS, HT(ASCP)HTL



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RE: [Histonet] CAP

[Wanda.Smith]

Akemi,
Keep us informed!!!  I too, am in my CAP window!!!
Thanks,
Wanda

WANDA G. SMITH, HTL(ASCP)HT
Pathology Supervisor
TRIDENT MEDICAL CENTER
9330 Medical Plaza Drive
Charleston, SC  29406
843-847-4586
843-847-4296 fax

This email and any files transmitted with it may contain PRIVILEGED or 
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-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Akemi Allison
Sent: Wednesday, February 23, 2011 9:03 AM
To: histonet
Subject: [Histonet] CAP

Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our 
department 
did pretty good.  Keeping my fingers crossed.  
 Akemi Allison BS, HT(ASCP)HTL


  
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RE: [Histonet] CAP

[Jesus Ellin]

Akemi, were you inspected with the new CAP checklist or the old one?
The situation in our lab is that we were given the checklist and then
they changed us to the new format.  Your thoughts

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Akemi
Allison
Sent: Wednesday, February 23, 2011 7:03 AM
To: histonet
Subject: [Histonet] CAP

Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our
department 
did pretty good.  Keeping my fingers crossed.  
 Akemi Allison BS, HT(ASCP)HTL


  
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Re: [Histonet] CAP

[Angela Bitting]

We just had ours last week.
We did well, but the inspecting Pathologist said the lab smelled like oranges 
we were in a way too cramped space. Go figure..
 

 Akemi Allison akemiat3...@yahoo.com 2/23/2011 9:02 AM 
Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our 
department 
did pretty good.  Keeping my fingers crossed.  
Akemi Allison BS, HT(ASCP)HTL


  
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RE: [Histonet] CAP

[Wanda.Smith]

Sometimes it is a good thing when CAP says you are cramped for space.  It 
sometimes makes the hospital Administration wake up and take notice!!!
W

WANDA G. SMITH, HTL(ASCP)HT
Pathology Supervisor
TRIDENT MEDICAL CENTER
9330 Medical Plaza Drive
Charleston, SC  29406
843-847-4586
843-847-4296 fax

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-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Angela Bitting
Sent: Wednesday, February 23, 2011 10:29 AM
To: histonet; Akemi Allison
Subject: Re: [Histonet] CAP


We just had ours last week.
We did well, but the inspecting Pathologist said the lab smelled like oranges 
we were in a way too cramped space. Go figure..
 

 Akemi Allison akemiat3...@yahoo.com 2/23/2011 9:02 AM 
Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our 
department 
did pretty good.  Keeping my fingers crossed.  
Akemi Allison BS, HT(ASCP)HTL


  
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RE: [Histonet] CAP

[sgoebel]

What?!?  A histology lab with no enough space...who ever heard of such a
thing 

Sarah Goebel, BA, HT(ASCP)
Histotechnologist
Mirna Therapeutics
2150 Woodward Street
Suite 100
Austin, Texas  78744
(512)901-0900 ext. 6912

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Angela
Bitting
Sent: Wednesday, February 23, 2011 9:29 AM
To: histonet; Akemi Allison
Subject: Re: [Histonet] CAP


We just had ours last week.
We did well, but the inspecting Pathologist said the lab smelled like
oranges we were in a way too cramped space. Go figure..
 

 Akemi Allison akemiat3...@yahoo.com 2/23/2011 9:02 AM 
Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our
department 
did pretty good.  Keeping my fingers crossed.  
Akemi Allison BS, HT(ASCP)HTL


  
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Re: [Histonet] CAP

[DKBoyd]

That's a good thing!  That means you need more ventilation and admin 
listens when inspectors speak!


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







Angela Bitting akbitt...@geisinger.edu 
Sent by: histonet-boun...@lists.utsouthwestern.edu
02/23/2011 10:30 AM

To
histonet histonet@lists.utsouthwestern.edu, Akemi Allison 
akemiat3...@yahoo.com
cc

Subject
Re: [Histonet] CAP







We just had ours last week.
We did well, but the inspecting Pathologist said the lab smelled like 
oranges we were in a way too cramped space. Go figure..
 

 Akemi Allison akemiat3...@yahoo.com 2/23/2011 9:02 AM 
Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our 
department 
did pretty good.  Keeping my fingers crossed. 
Akemi Allison BS, HT(ASCP)HTL


 
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Re: [Histonet] CAP

[Akemi Allison]

We were given the new CAP checklist.  I totally revamped our SOP Manuals, ALL 
QC 
forms, etc. to comply.  


This is the 1st Childrens Hospital CAP inspection I have undergone.  We are 
inspected by other Children Hospital inspecting teams.  


After all the hard work, they did not go through any of our SOP's, QC manuals, 
Special Stains, validation protocols manuals for either histology or the IHC 
lab.  Very odd indeed.  


They spoke with the AP manager for our department only, except to ask one of 
the 
histology techs how we disposed of our hazardous waste. Stay tuned till after 
the summation.
 Akemi Allison BS, HT(ASCP)HTL








From: Jesus Ellin jel...@yumaregional.org
To: Akemi Allison akemiat3...@yahoo.com; histonet 
histonet@lists.utsouthwestern.edu
Sent: Wed, February 23, 2011 7:23:43 AM
Subject: RE: [Histonet] CAP

Akemi, were you inspected with the new CAP checklist or the old one?
The situation in our lab is that we were given the checklist and then
they changed us to the new format.  Your thoughts

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Akemi
Allison
Sent: Wednesday, February 23, 2011 7:03 AM
To: histonet
Subject: [Histonet] CAP

Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our
department 
did pretty good.  Keeping my fingers crossed.  
Akemi Allison BS, HT(ASCP)HTL


      
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Re: [Histonet] CAP

[Jay Lundgren]

 If your lab smells like oranges, just open your CAP window and air it
out.


  Sincerely,

  Jay A.
Lundgren M.S., HTL (ASCP)
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Re: [Histonet] CAP

[Angela Bitting]

I did notice CAP inspectors concentrated more on safety this time around.

 Akemi Allison akemiat3...@yahoo.com 2/23/2011 11:50 AM 
We were given the new CAP checklist.  I totally revamped our SOP Manuals, ALL 
QC 
forms, etc. to comply.  


This is the 1st Childrens Hospital CAP inspection I have undergone.  We are 
inspected by other Children Hospital inspecting teams.  


After all the hard work, they did not go through any of our SOP's, QC manuals, 
Special Stains, validation protocols manuals for either histology or the IHC 
lab.  Very odd indeed.  


They spoke with the AP manager for our department only, except to ask one of 
the 
histology techs how we disposed of our hazardous waste. Stay tuned till after 
the summation.
Akemi Allison BS, HT(ASCP)HTL








From: Jesus Ellin jel...@yumaregional.org
To: Akemi Allison akemiat3...@yahoo.com; histonet 
histonet@lists.utsouthwestern.edu
Sent: Wed, February 23, 2011 7:23:43 AM
Subject: RE: [Histonet] CAP

Akemi, were you inspected with the new CAP checklist or the old one?
The situation in our lab is that we were given the checklist and then
they changed us to the new format.  Your thoughts

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Akemi
Allison
Sent: Wednesday, February 23, 2011 7:03 AM
To: histonet
Subject: [Histonet] CAP

Lot's of Labs in LA are in their CAP window!  We had our CAP inspection 
yesterday and having our summation this morning at 9:00.  I think our
department 
did pretty good.  Keeping my fingers crossed.  
Akemi Allison BS, HT(ASCP)HTL


  
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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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RE: [Histonet] CAP ANP.22760

[Laurie Colbert]

Matt,

We have Ventana stainers, and I have a comment on your first question
and would welcome input from others on this topic.
We cannot run parallel validations on either the Benchmarks or the
Ultras, so I have stated that in my validation procedure.  There's
nothing I can do about it.

Laurie Colbert

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Matthew
Lunetta
Sent: Monday, February 07, 2011 12:19 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP ANP.22760

hey All,
My question is directed to those Hospital labs that have 1(one) DAKO
instrument. 
1) How are you handling the 'parallel' of this question?
2) What is your validation of the visualization system protocol?
3) How are you running your validation of anti-bodies?
We have a few protocols that we have been trying and want to see what
others have come up with.
Thanks,
Matt Lunetta HT(ASCP)
Longmont United Hospital
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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,
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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
 
 
 
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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



 ___
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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

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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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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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
 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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or are not the named recipient(s), please notify the sender 
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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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RE: [Histonet] CAP Checklist

[McMahon, Loralee A]

They will send you a copy of the checklist that you will be inspected under 
before your inspection.  They do not publish it that I know of.  


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 thisis...@aol.com 
[thisis...@aol.com]
Sent: Tuesday, April 20, 2010 4:56 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP Checklist

Can someone tell me where on the CAP website I can get a copy of the checklist 
to prepare for an inspection (for all departments, not just Histology...etc. 
Cytology, FISH, PCR).
Thank you,  Ann



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RE: [Histonet] CAP standard for formalin and xyelene testing

[Mahoney,Janice A]

My understanding is that it is the job, not the employee that must be 
monitored.  So if you have three people using the same process of changing the 
stainer, only one of those people needs to be tested.
Please correct me if I am wrong.
Thanks,
Jan Mahoney
Omaha, NE

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Jeffrey 
Silverman
Sent: Monday, January 18, 2010 4:19 PM
To: sjkit...@live.com
Cc: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP standard for formalin and xyelene testing

CAP standard says formaldehyde testing should be done for each employee as an 
eight hour exposure and a short term exposure limit. If two tests done at least 
one week apart are under action levels, there is no need for further ongoing 
monitoring unless new process, employee, or other factor that might increase 
exposure is introduced. Or if an employee feels they have a problem and 
requests it. So I guess each employee is tested twice and then that's it unless 
you over the limit.

Xylene is similar- once you have two tests under action levels, there is no 
need for ongoing monitoring unless things change as above.

Jeffrey Silverman HT HTL QIHC (ASCP)
Pathologists' Assistant- Lab Safety Officer
Southside Hospital NSLIJHS
 Bay Shore, NY USA
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RE: [Histonet] CAP standard for formalin and xyelene testing

[Percival Karen]

Some time ago, I had tested each one of my staff doing the same procedures for 
both formaldehyde and xylene.  Procedures included, autostaining, processor 
changes, staining rack changes, recycling, and disposal procedures.  Everyone 
except for one person was within normal limits.  This one person was tested 
several times over, and his/her results continued to be outside of the 
acceptable range for both long and short-term exposure limits.  Finally, we had 
to physically observe this person doing his/her job for both the short and 
long-term exposure tests.  
 
Long story short, this person was simply working too quickly and was not being 
as cautious as s/he should have been.  Splashing occurred all too frequently.  
Although s/he followed the same procedures and protocols for all of his/her 
activities as the other staff members, his/her level of carelessness caused 
his/her monitor badge readings to constantly be above the acceptable limits.
 
Test everyone.
 
 
 
Karen Percival, BS, HT
Research Scientist II
Pfizer Research DSRD
1 Burtt Road
G3025
Andover, MA 01810
888-577-1500 x 4058
kpercival @wyeth.com

 Mahoney,Janice A janice.maho...@alegent.org 1/19/2010 9:15 AM 

My understanding is that it is the job, not the employee that must be 
monitored.  So if you have three people using the same process of changing the 
stainer, only one of those people needs to be tested.
Please correct me if I am wrong.
Thanks,
Jan Mahoney
Omaha, NE

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Jeffrey 
Silverman
Sent: Monday, January 18, 2010 4:19 PM
To: sjkit...@live.com 
Cc: histonet@lists.utsouthwestern.edu 
Subject: [Histonet] CAP standard for formalin and xyelene testing

CAP standard says formaldehyde testing should be done for each employee as an 
eight hour exposure and a short term exposure limit. If two tests done at least 
one week apart are under action levels, there is no need for further ongoing 
monitoring unless new process, employee, or other factor that might increase 
exposure is introduced. Or if an employee feels they have a problem and 
requests it. So I guess each employee is tested twice and then that's it unless 
you over the limit.

Xylene is similar- once you have two tests under action levels, there is no 
need for ongoing monitoring unless things change as above.

Jeffrey Silverman HT HTL QIHC (ASCP)
Pathologists' Assistant- Lab Safety Officer
Southside Hospital NSLIJHS
Bay Shore, NY USA
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Unauthorized use, disclosure, distribution or copying is strictly prohibited 
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RE: [Histonet] CAP standard for formalin and xyelene testing

[Kim . Donadio]

Jan, You are correct. It is the task. Must like when doing proficiency 
testing, rotate employees on all of these task. While I agree with Karen 
that it is probably best practice to do all of them, it is not required. 




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



Percival Karen kperci...@wyeth.com 
Sent by: histonet-boun...@lists.utsouthwestern.edu
01/19/2010 08:47 AM

To
Mahoney Janice A janice.maho...@alegent.org, sjkit...@live.com 
sjkit...@live.com, Silverman' 'Jeffrey pathmas...@yahoo.com
cc
histonet@lists.utsouthwestern.edu histonet@lists.utsouthwestern.edu
Subject
RE: [Histonet] CAP standard for formalin and xyelene testing






Some time ago, I had tested each one of my staff doing the same procedures 
for both formaldehyde and xylene.  Procedures included, autostaining, 
processor changes, staining rack changes, recycling, and disposal 
procedures.  Everyone except for one person was within normal limits. This 
one person was tested several times over, and his/her results continued to 
be outside of the acceptable range for both long and short-term exposure 
limits.  Finally, we had to physically observe this person doing his/her 
job for both the short and long-term exposure tests. 
 
Long story short, this person was simply working too quickly and was not 
being as cautious as s/he should have been.  Splashing occurred all too 
frequently.  Although s/he followed the same procedures and protocols for 
all of his/her activities as the other staff members, his/her level of 
carelessness caused his/her monitor badge readings to constantly be above 
the acceptable limits.
 
Test everyone.
 
 
 
Karen Percival, BS, HT
Research Scientist II
Pfizer Research DSRD
1 Burtt Road
G3025
Andover, MA 01810
888-577-1500 x 4058
kpercival @wyeth.com

 Mahoney,Janice A janice.maho...@alegent.org 1/19/2010 9:15 AM 

My understanding is that it is the job, not the employee that must be 
monitored.  So if you have three people using the same process of changing 
the stainer, only one of those people needs to be tested.
Please correct me if I am wrong.
Thanks,
Jan Mahoney
Omaha, NE

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Jeffrey 
Silverman
Sent: Monday, January 18, 2010 4:19 PM
To: sjkit...@live.com 
Cc: histonet@lists.utsouthwestern.edu 
Subject: [Histonet] CAP standard for formalin and xyelene testing

CAP standard says formaldehyde testing should be done for each employee as 
an eight hour exposure and a short term exposure limit. If two tests done 
at least one week apart are under action levels, there is no need for 
further ongoing monitoring unless new process, employee, or other factor 
that might increase exposure is introduced. Or if an employee feels they 
have a problem and requests it. So I guess each employee is tested twice 
and then that's it unless you over the limit.

Xylene is similar- once you have two tests under action levels, there is 
no need for ongoing monitoring unless things change as above.

Jeffrey Silverman HT HTL QIHC (ASCP)
Pathologists' Assistant- Lab Safety Officer
Southside Hospital NSLIJHS
Bay Shore, NY USA
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Alegent Health is faithful to the healing ministry of Jesus Christ, 
providing high quality care for the body, mind and spirit of every person.

The information contained in this communication, including attachments, is 
confidential and private and intended only for the use of the addressees. 
Unauthorized use, disclosure, distribution or copying is strictly 
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error, please inform us of the erroneous delivery by return e-mail message 
from your computer.  Additionally, although all attachments have been 
scanned at the source for viruses, the recipient should check any 
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this e-mail.  Thank you for your cooperation.


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RE: [Histonet] CAP standard for formalin and xyelene testing

[Rene J Buesa]

Not all histotechs work in the same way, so I always monitored the job (as 
Janice points out) but also the staff member. I remember having different 
results for staff for the same task.
We used to monitor the whole staff (21) during a whole year, meaning that each 
month there was somebody being tested. We monitores for formalin and xylene, 
until we stop using xylene.
We also had an outside company to monitor the whole lab during one single day.
René J.

--- On Tue, 1/19/10, Mahoney,Janice A janice.maho...@alegent.org wrote:


From: Mahoney,Janice A janice.maho...@alegent.org
Subject: RE: [Histonet] CAP standard for formalin and xyelene testing
To: 'Jeffrey Silverman' pathmas...@yahoo.com, sjkit...@live.com 
sjkit...@live.com
Cc: histonet@lists.utsouthwestern.edu histonet@lists.utsouthwestern.edu
Date: Tuesday, January 19, 2010, 9:15 AM


My understanding is that it is the job, not the employee that must be 
monitored.  So if you have three people using the same process of changing the 
stainer, only one of those people needs to be tested.
Please correct me if I am wrong.
Thanks,
Jan Mahoney
Omaha, NE

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Jeffrey 
Silverman
Sent: Monday, January 18, 2010 4:19 PM
To: sjkit...@live.com
Cc: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP standard for formalin and xyelene testing

CAP standard says formaldehyde testing should be done for each employee as an 
eight hour exposure and a short term exposure limit. If two tests done at least 
one week apart are under action levels, there is no need for further ongoing 
monitoring unless new process, employee, or other factor that might increase 
exposure is introduced. Or if an employee feels they have a problem and 
requests it. So I guess each employee is tested twice and then that's it unless 
you over the limit.

Xylene is similar- once you have two tests under action levels, there is no 
need for ongoing monitoring unless things change as above.

Jeffrey Silverman HT HTL QIHC (ASCP)
Pathologists' Assistant- Lab Safety Officer
Southside Hospital NSLIJHS
Bay Shore, NY USA
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Sponsored by Catholic Health Initiatives and Immanuel Health Systems, Alegent 
Health is faithful to the healing ministry of Jesus Christ, providing high 
quality care for the body, mind and spirit of every person.

The information contained in this communication, including attachments, is 
confidential and private and intended only for the use of the addressees.  
Unauthorized use, disclosure, distribution or copying is strictly prohibited 
and may be unlawful.  If you received this communication in error, please 
inform us of the erroneous delivery by return e-mail message from your 
computer.  Additionally, although all attachments have been scanned at the 
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of viruses before opening.  Alegent Health accepts no liability for any damage 
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RE: [Histonet] CAP standard for formalin and xyelene testing

[Terri Braud]

We also monitored by task, and by employee with badges.  But, even though we've 
never been over threshold limits, we have an outside company come in once per 
year.  Its a precautionary step lest the least procedural change slip by us.  
This also acts as an insurance for those that might seek to find fault with our 
monitoring.  As we all know, you can smell xylene long before it becomes 
dangerous.

Terri L. Braud, HT(ASCP)
Anatomic Pathology Supervisor
Laboratory
Holy Redeemer Hospital and Medical Center
1648 Huntingdon Pike
Meadowbrook, PA 19046
(215) 938-3676 phone
(215) 938-3689 fax


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu]on Behalf Of Rene J
Buesa
Sent: Tuesday, January 19, 2010 16:38
To: 'Jeffrey Silverman'; sjkit...@live.com; Janice AMahoney
Cc: histonet@lists.utsouthwestern.edu
Subject: RE: [Histonet] CAP standard for formalin and xyelene testing


Not all histotechs work in the same way, so I always monitored the job (as 
Janice points out) but also the staff member. I remember having different 
results for staff for the same task.
We used to monitor the whole staff (21) during a whole year, meaning that each 
month there was somebody being tested. We monitores for formalin and xylene, 
until we stop using xylene.
We also had an outside company to monitor the whole lab during one single day.
René J.

--- On Tue, 1/19/10, Mahoney,Janice A janice.maho...@alegent.org wrote:


From: Mahoney,Janice A janice.maho...@alegent.org
Subject: RE: [Histonet] CAP standard for formalin and xyelene testing
To: 'Jeffrey Silverman' pathmas...@yahoo.com, sjkit...@live.com 
sjkit...@live.com
Cc: histonet@lists.utsouthwestern.edu histonet@lists.utsouthwestern.edu
Date: Tuesday, January 19, 2010, 9:15 AM


My understanding is that it is the job, not the employee that must be 
monitored.  So if you have three people using the same process of changing the 
stainer, only one of those people needs to be tested.
Please correct me if I am wrong.
Thanks,
Jan Mahoney
Omaha, NE

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Jeffrey 
Silverman
Sent: Monday, January 18, 2010 4:19 PM
To: sjkit...@live.com
Cc: histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP standard for formalin and xyelene testing

CAP standard says formaldehyde testing should be done for each employee as an 
eight hour exposure and a short term exposure limit. If two tests done at least 
one week apart are under action levels, there is no need for further ongoing 
monitoring unless new process, employee, or other factor that might increase 
exposure is introduced. Or if an employee feels they have a problem and 
requests it. So I guess each employee is tested twice and then that's it unless 
you over the limit.

Xylene is similar- once you have two tests under action levels, there is no 
need for ongoing monitoring unless things change as above.

Jeffrey Silverman HT HTL QIHC (ASCP)
Pathologists' Assistant- Lab Safety Officer
Southside Hospital NSLIJHS
Bay Shore, NY USA
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quality care for the body, mind and spirit of every person.

The information contained in this communication, including attachments, is 
confidential and private and intended only for the use of the addressees.  
Unauthorized use, disclosure, distribution or copying is strictly prohibited 
and may be unlawful.  If you received this communication in error, please 
inform us of the erroneous delivery by return e-mail message from your 
computer.  Additionally, although all attachments have been scanned at the 
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of viruses before opening.  Alegent Health accepts no liability for any damage 
caused by any virus transmitted by this e-mail.  Thank you for your cooperation.


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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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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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sender that you have received the message in 

 

error, then delete this message.

 

 

 

 

 

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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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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 guidelines for positive controls

[Rene J Buesa]

They should be kept to comply with your policies and the state requirements.
Remember that CAP has regulations but cannot override state nor institutional 
policies.
René J.

--- On Fri, 11/20/09, Tiana Fountain tfount...@exchange.hsc.mb.ca wrote:


From: Tiana Fountain tfount...@exchange.hsc.mb.ca
Subject: [Histonet] CAP guidelines for positive controls
To: histonet@lists.utsouthwestern.edu
Date: Friday, November 20, 2009, 12:14 PM


Hello,

I am trying to find the guidelines for CAP that describes how long IHC
positive control slides are to be kept on file ... does anyone know? 

Thanks in advance!

Tiana



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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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RE: [Histonet] cap survays

[Tony Henwood]

Edie,

What a challenge.
I would strongly recommend you give it a go.
I like to score fixation, processing and staining quality of slides I
and my staff produce.
It allows us to have control over the science of histotechnology not the
pathologists (they have enough to worry about - the diagnosis, clinical
demands etc).

When a department runs this way, it does not take long for the
pathologist to realise the invaluable resource their labs are. In fact
they become quite proud of it!

Regards

Tony Henwood JP, MSc, BAppSc, GradDipSysAnalys, CT(ASC)
Laboratory Manager  Senior Scientist
Tel: 612 9845 3306
Fax: 612 9845 3318
the children's hospital at westmead 
Cnr Hawkesbury Road and Hainsworth Street, Westmead 
Locked Bag 4001, Westmead NSW 2145, AUSTRALIA 




-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of
Gonzales, Edith
Sent: Friday, 25 September 2009 5:50 AM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] cap survays



To all,

I would like to know what everyone is doing with the cap survay now that
it is scoring staining performance and not detremining a diagnosis.  Our
paths want us to score then and they not be involved.  Is this what
everone else is doing?

Edie


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RE: [Histonet] CAP ?

[Tom McNemar]

Most of that info should be available on the MSDS.  Ours are available on the 
hospital network but we used to just keep a binder.

Tom McNemar, HT(ASCP)
Histology Co-ordinator
Licking Memorial Health Systems
(740) 348-4163
(740) 348-4166
tmcne...@lmhealth.org
www.LMHealth.org


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu]on Behalf Of Vacca
Jessica
Sent: Monday, August 10, 2009 10:06 AM
To: Histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP ?


How does one gather this information in the lab? What are your steps?

GEN.70550  Is there documentation that each of the chemicals in the laboratory 
has been evaluated for carcinogenic potential, reproductive toxicity, and acute 
toxicity; and does the policies and procedure manual define specific handling 
requirements for these chemicals -

Thanks

Jessica Vacca
Histology Supervisor
119 Oakfield Dr
Brandon Fl 33511
(813) 571-5193
(813) 571-5169 FAX
  



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RE: [Histonet] CAP ? (UNCLASSIFIED)

[Gladney, Diane C Ms CIV USA MEDCOM MACH]

Classification:  UNCLASSIFIED 
Caveats: NONE

We have a  MSDS for all of our chemicals. The information is listed in the 
MSDS. We keep copies in our MSDS Books in the lab for fast and easy access. The 
MSDS's are updated yearly, when we receive new chemicals or the manufacturer 
sends us their latest MSDS on their products. This use of the MSDS and the 
information listed is addressed in our Safety Standard Operating Procedures 
(SOP). We also list in this SOP all known carcinogens, reproductive toxicity 
and acute toxicity used in the lab. They are to be handled in accordance with 
the recommendations of the MSDS. 

Thanks,
Diane G. 

Diane C. Gladney, HT (ASCP)
Supervisor, Anatomical Pathology 
Moncrief Army Community Hospital
Dept. of Pathology
4500 Stuart St.
FT. Jackson, SC  29207

Email:  diane.glad...@amedd.army.mil

Phone:  803-751- 2530 
FAX: 803-751-7829
DSN:    734-2530






-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu 
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Vacca Jessica
Sent: Monday, August 10, 2009 10:06 AM
To: Histonet@lists.utsouthwestern.edu
Subject: [Histonet] CAP ?

How does one gather this information in the lab? What are your steps?

GEN.70550  Is there documentation that each of the chemicals in the laboratory 
has been evaluated for carcinogenic potential, reproductive toxicity, and acute 
toxicity; and does the policies and procedure manual define specific handling 
requirements for these chemicals -

Thanks

Jessica Vacca
Histology Supervisor
119 Oakfield Dr
Brandon Fl 33511
(813) 571-5193
(813) 571-5169 FAX
  



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Classification:  UNCLASSIFIED 
Caveats: NONE


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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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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

[Rene J Buesa]

This aspect has to be part of your contingency plan and each lab, with its own 
idiosyncrasies, has to prepare one, like what to do during/after a hurricane.
René J.

--- On Tue, 3/10/09, Behnaz Sohrab sohra...@ah.org wrote:

From: Behnaz Sohrab sohra...@ah.org
Subject: [Histonet] CAP
To: histonet@lists.utsouthwestern.edu
Date: Tuesday, March 10, 2009, 12:49 PM

Does any one have a procedure regarding :  Handling of work load during
instrument failure .?
This would include, VIP,embedding ,etc...
Behnaz Sohrab


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RE: [Histonet] Cap checklist question

[Charles.Embrey]

NO,NO,NO, CAP does not call grossing tissue, processing tissue.  CAP
has made two categories or specimens- Processing and grossing.
ANP.11600
1. Processing is defined as a tissue examination limited to description,
inking and cutting of the specimen (if applicable), and submission of
the entire specimen to histology.  Tissue processing can be performed
according to standardized protocols.  Processing is generally limited to
small specimens (skin, small biopsies, curettings, etc.) and does not
require knowledge of anatomy.
2.  Grossing (or gross examination) is defined as a tissue examination
requiring a greater exercise of judgment and a knowledge of anatomy.
Dissection of the specimen and selection of tissue samples for
submission to histology are generally required.  The specimen
description is not necessarily standardized.

CAP goes on to require grossing be done by a pathologist or
pathologist resident or other individuals qualifying as high complexity
testing personnel under CLIA 88 regulations.  The written procedures
asked about in ANP.11665 apply only to processing as defined by CAP
when being done by non-pathologist individuals who are not qualified as
high complexity testing personnel under CLIA 88.

Charles Embrey, PA(ASCP)


-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Joyce
Cline
Sent: Tuesday, February 03, 2009 12:21 PM
To: Histonet
Subject: RE: [Histonet] Cap checklist question


ANP.11665 refers to a non PA or non pathologist grossing tissue. CAP
calls
grossing tissue processing specimens. There has to be a manual with
all
grossing techniques such as Ackermans' Pathology or a manual made at
the
site.
ANP.22990 deals with performing FISH  ISH, there should be tech samples
that can be ordered from CAP, I would check the web site. But if you do
not
perform FISH or ISH, the question is N/A.


+++

-Original Message-
From: histonet-boun...@lists.utsouthwestern.edu
[mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Scott,
Allison D
Sent: Monday, February 02, 2009 5:44 PM
To: histonet@lists.utsouthwestern.edu
Subject: [Histonet] Cap checklist question

I have a question concerning CAP checklist question ANP.11665. Are .
there written procedures for processing specimens.  Is this referring to
tech's or to residents that are grossing.  We only have pathology
residents grossing and taking care of specimens. What are predictive
markers, this refers to ANP.22990.  This is a new checklist question.
Any help would be greatly appreciated.

 

Allison Scott HT(ASCP)

Histology Supervisor

LBJ Hospital

Houston, Texas 77026

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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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