Re: [Histonet] RE: competency form
We have the same issue. It is bad when they try to use the same QA form for out of range proficiency testing. a +3 or +4 is IHC is not the same as 70 or 200 glucose result. The pathologists are haven real issues with it as well. S. Paturzo ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form- Inspector Perspective.
Thank you- good reminder of what the true goals are. Joelle Weaver MAOM, HTL (ASCP) QIHC From: ibern...@uab.edu To: trathbo...@somerset-healthcare.com; sm...@msn.com; joellewea...@hotmail.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form- Inspector Perspective. Date: Thu, 10 Apr 2014 01:57:10 + I recently had the great honor to serve as a CAP inspector in Arizona. The lab we inspected will be accredited. Lest we forget as inspectors or future inspectors, I hope the below perspective illuminates the purpose of the CAP inspection and helps preserve the integrity of the program if adhered to. As inspectors, we are trained to be thorough but to simultaneously use objective judgment i.e. there may be several ways to meet the intent of the question and that we must review all pertinent documentation and then determine if the process meets the intent of the requirement. Keeping in mind that the purpose of CAP inspection is not punitive but quality laboratory improvement to fulfill the regulatory purpose of the inspection (CLIA). Our focus should be, in the interest of time and thoroughness major compliance issue rather than nitpick. This helps us maintain professionalism and preserve the peer-review nature of the program. So what is it that constitutes compliance? Per CAP: - One, that the laboratory has defined a policy, a procedure, or a plan of the three P's for how they are going to do things in the lab. - Secondly, actual practices that matches those three P's. - Finally, documentation to support the fact that practice has indeed matched policies and procedures. So what is a deficiency? Per CAP: A deficiency means that the lab did not meet the intent of the checklist item. It's not the wording; it's not the specifics. It is the intent. If any of the three above criteria are not yet met, we should cite a deficiency We are admonished to remember that there may be many ways to accomplish an objective. The lab may not do things exactly the way that your lab does, but may still be meeting the intent of the requirement(s). Citing a laboratory for not doing it the way we do it is a common inspector error. Per CAP, partial compliance is the following: If there is partial compliance (e.g., some records are inconsistent, one bottle of reagent was not labeled completely, a few temperatures were not recorded, etc.), you must judge whether the degree of non-compliance is likely to have adverse effects on test accuracy, patient care, or worker safety. Also, determine if the lab staff was aware of the inconsistency and if corrective actions were performed. If adverse effects are likely or if there are definite patterns (e.g., missing temperatures only on weekends) without corrective actions only then we must cite a deficiency. Bottom-line, If you feel you were incorrectly cited since you met the intent of the question, you should appeal to CAP. It is an inspected lab's right. If a phase 11 deficiency, submit your evidence of compliance and the Lab Accreditation Committee will either overrule or sustain. I suspect they will overrule. Just saying, but based upon just what you described, it sounds like you all met the intent of the question. MSgt Ian R Bernard, HT(ASCP), MSHA-UAB Anatomic Pathology Lab Manager USAF- Active Duty ibern...@uab.edu ian.bern...@comcast.net -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Rathborne, Toni Sent: Wednesday, April 09, 2014 7:04 AM To: 'Sheila Haas'; joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form CAP inspectors may have opinions which differ from our own, and their interpretation of standards may also be different. Have you challenged this deficiency with CAP? -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Sheila Haas Sent: Wednesday, April 09, 2014 8:52 AM To: joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task documented along with any corrective action necessary; the correlation of proficiency tests, educational assessments and performance reviews for technical staff; daily evaluations from the pathologists concerning staining, microtomy and grossing; and educational training documentation. We had no idea with all pieces of this documentation that we were anticipated to have more. The form for DO of each task was not detailed enough (despite
RE: [Histonet] RE: competency form- Inspector Perspective.
Well said Ian and I couldn't agree more. I certainly understand the need for consistency and regulations. We are appealing a couple of our deficiencies because we have the documentation although it was not documented the way the inspectors wanted to see it (as part of a particular form); instead we have a couple of forms which captures the information in a number of ways. We'll see what CAP says...stay tuned. Thanks to everyone for their input and information. It is greatly appreciated. Sheila Haas MicroPath Laboratories, Inc. From: ibern...@uab.edu To: trathbo...@somerset-healthcare.com; sm...@msn.com; joellewea...@hotmail.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form- Inspector Perspective. Date: Thu, 10 Apr 2014 01:57:10 + I recently had the great honor to serve as a CAP inspector in Arizona. The lab we inspected will be accredited. Lest we forget as inspectors or future inspectors, I hope the below perspective illuminates the purpose of the CAP inspection and helps preserve the integrity of the program if adhered to. As inspectors, we are trained to be thorough but to simultaneously use objective judgment i.e. there may be several ways to meet the intent of the question and that we must review all pertinent documentation and then determine if the process meets the intent of the requirement. Keeping in mind that the purpose of CAP inspection is not punitive but quality laboratory improvement to fulfill the regulatory purpose of the inspection (CLIA). Our focus should be, in the interest of time and thoroughness major compliance issue rather than nitpick. This helps us maintain professionalism and preserve the peer-review nature of the program. So what is it that constitutes compliance? Per CAP: - One, that the laboratory has defined a policy, a procedure, or a plan of the three P's for how they are going to do things in the lab. - Secondly, actual practices that matches those three P's. - Finally, documentation to support the fact that practice has indeed matched policies and procedures. So what is a deficiency? Per CAP: A deficiency means that the lab did not meet the intent of the checklist item. It's not the wording; it's not the specifics. It is the intent. If any of the three above criteria are not yet met, we should cite a deficiency We are admonished to remember that there may be many ways to accomplish an objective. The lab may not do things exactly the way that your lab does, but may still be meeting the intent of the requirement(s). Citing a laboratory for not doing it the way we do it is a common inspector error. Per CAP, partial compliance is the following: If there is partial compliance (e.g., some records are inconsistent, one bottle of reagent was not labeled completely, a few temperatures were not recorded, etc.), you must judge whether the degree of non-compliance is likely to have adverse effects on test accuracy, patient care, or worker safety. Also, determine if the lab staff was aware of the inconsistency and if corrective actions were performed. If adverse effects are likely or if there are definite patterns (e.g., missing temperatures only on weekends) without corrective actions only then we must cite a deficiency. Bottom-line, If you feel you were incorrectly cited since you met the intent of the question, you should appeal to CAP. It is an inspected lab's right. If a phase 11 deficiency, submit your evidence of compliance and the Lab Accreditation Committee will either overrule or sustain. I suspect they will overrule. Just saying, but based upon just what you described, it sounds like you all met the intent of the question. MSgt Ian R Bernard, HT(ASCP), MSHA-UAB Anatomic Pathology Lab Manager USAF- Active Duty ibern...@uab.edu ian.bern...@comcast.net -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Rathborne, Toni Sent: Wednesday, April 09, 2014 7:04 AM To: 'Sheila Haas'; joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form CAP inspectors may have opinions which differ from our own, and their interpretation of standards may also be different. Have you challenged this deficiency with CAP? -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Sheila Haas Sent: Wednesday, April 09, 2014 8:52 AM To: joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task
Re: [Histonet] RE: competency form
I was having the same problems with developing competency records for my cytotechnologist. I found this article from ADVACE for Adminstrators to be very helpful in creating my competency forms. We just had an on-site CAP inspection and it seemed to satisfy them. Hope this link is helpful. The article's author is Teresa Scott. http://laboratory-manager.advanceweb.com/Web-Extras/Online-Extras/Competency-Assessment.aspx Valerie Biendara SCT(ASCP)IAC Cytology Supervisor NWA Pathology Associates Demarinis wrote: = I would be interested in reviewing the competency form. Could you email it to me as well? Thanks. Carolyn - cdemari...@saratogacare.org -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Amber McKenzie Sent: Tuesday, April 08, 2014 5:18 PM To: Houston, Ronald; Histonet Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto:ronald.hous...@nationwidechildrens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify Saratoga Hospital immediately by e-mail at priv...@saratogacare.org and destroy all copies of this communication and any attachments. ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
Has some nice tables that summarize things for a good starting point especially if you are building from scratch . Thank you for sharing this. Joelle Weaver MAOM, HTL (ASCP) QIHC Date: Thu, 10 Apr 2014 10:36:01 -0400 From: cyt...@cox.net To: histonet@lists.utsouthwestern.edu Subject: Re: [Histonet] RE: competency form I was having the same problems with developing competency records for my cytotechnologist. I found this article from ADVACE for Adminstrators to be very helpful in creating my competency forms. We just had an on-site CAP inspection and it seemed to satisfy them. Hope this link is helpful. The article's author is Teresa Scott. http://laboratory-manager.advanceweb.com/Web-Extras/Online-Extras/Competency-Assessment.aspx Valerie Biendara SCT(ASCP)IAC Cytology Supervisor NWA Pathology Associates Demarinis wrote: = I would be interested in reviewing the competency form. Could you email it to me as well? Thanks. Carolyn - cdemari...@saratogacare.org -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Amber McKenzie Sent: Tuesday, April 08, 2014 5:18 PM To: Houston, Ronald; Histonet Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto:ronald.hous...@nationwidechildrens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify Saratoga Hospital immediately by e-mail at priv...@saratogacare.org and destroy all copies of this communication and any attachments. ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
We were recently dinged by CAP for our competency assessments in all areas. While that's no longer my immediate responsibility, I would love to be able to assist the lab manager with some information so we can tweek our assessments if you all wouldn't mind sharing with me as well. Thanks a bunch. Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: amber.mcken...@gastrodocs.net To: ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Tue, 8 Apr 2014 21:17:44 + CC: Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto:ronald.hous...@nationwidechildrens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
I don't know if it's reasonable to share with all of us, but I bet there are a lot of us that would be interested in how others are approaching these topics. I doubt there are that many workshops on the issue-or have there been teleconferences maybe that cover the subject? _Sally Sally Ann Drew,MT(ASCP) UW SMPH-Dept. of Pathology TRIP/TSB-TRIP Lab Manager CSC, K4/435 608.265.4378 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Amber McKenzie Sent: Tuesday, April 08, 2014 4:18 PM To: Houston, Ronald; Histonet Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto:ronald.houston@nationwidechild rens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
Re: [Histonet] RE: competency form
We based ours off the Michigan Society of Histotechnologist's Competency Assessment Handbook (available on their website for a nominal fee). We took some of their forms/ideas and modified them for our use. Patrick Laurie(HT)ASCP QIHC Histology Manager Celligent Diagnostics, LLC 101 East W.T. Harris Blvd | Suite 1212 | Charlotte, NC 28262 Work: 704-970-3300 Cell: 704-266-0869 On Wed, Apr 9, 2014 at 8:19 AM, Sally Ann Drew sad...@wisc.edu wrote: I don't know if it's reasonable to share with all of us, but I bet there are a lot of us that would be interested in how others are approaching these topics. I doubt there are that many workshops on the issue-or have there been teleconferences maybe that cover the subject? _Sally Sally Ann Drew,MT(ASCP) UW SMPH-Dept. of Pathology TRIP/TSB-TRIP Lab Manager CSC, K4/435 608.265.4378 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Amber McKenzie Sent: Tuesday, April 08, 2014 4:18 PM To: Houston, Ronald; Histonet Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto: ronald.houston@nationwidechild rens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
Thanks for the reference Patrick! Date: Wed, 9 Apr 2014 08:22:34 -0400 From: foreig...@gmail.com To: sad...@wisc.edu Subject: Re: [Histonet] RE: competency form CC: histonet@lists.utsouthwestern.edu; ronald.hous...@nationwidechildrens.org We based ours off the Michigan Society of Histotechnologist's Competency Assessment Handbook (available on their website for a nominal fee). We took some of their forms/ideas and modified them for our use. Patrick Laurie(HT)ASCP QIHC Histology Manager Celligent Diagnostics, LLC 101 East W.T. Harris Blvd | Suite 1212 | Charlotte, NC 28262 Work: 704-970-3300 Cell: 704-266-0869 On Wed, Apr 9, 2014 at 8:19 AM, Sally Ann Drew sad...@wisc.edu wrote: I don't know if it's reasonable to share with all of us, but I bet there are a lot of us that would be interested in how others are approaching these topics. I doubt there are that many workshops on the issue-or have there been teleconferences maybe that cover the subject? _Sally Sally Ann Drew,MT(ASCP) UW SMPH-Dept. of Pathology TRIP/TSB-TRIP Lab Manager CSC, K4/435 608.265.4378 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Amber McKenzie Sent: Tuesday, April 08, 2014 4:18 PM To: Houston, Ronald; Histonet Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto: ronald.houston@nationwidechild rens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
Is the question that Ronnie posed yesterday requesting justification of the need and extent of competency documentation for histology, or is it just a form needed? The general checklist pretty much sums up the necessity for doing, and required elements to me- GEN. 55500 and CLIA. Maybe I am not understanding? As for a form, I would expect that the specific items on any forms will vary by your personnel and by the testing and processes you perform. What I did to document initial training and competency was a make a summary checklist for each bench with tasks and direct observations DO for initial training documentation of satisfactory performance before patient testing. I just put all those checklists together in a summary table for each person. High complexity; such as grossing, IHC, FISH scoring get more attention and documentation, the waived tests, you have more discretion,- but I thought it easier to do everything about the same. I have not been inspected on this document yet ( so can't say if CAP will have issues with it- but will know soon...) but here is basically what I did to meet GEN.55500 or the main parts; Defined how competency is monitored- method and frequency ( just included as part of the competency SOP) Orientation and initial training documentation in a checklist for general lab, safety Training checklist on each technical bench, instrument, major procedure PT records and performance/results DO- a practical assessment ( block, slides, stains), for the assessment of previously analyzed specimens, and a PI feedback checklist for the technical from this audit of issues- how/what to improve Check off in performing QC, calibration, patient ID procedures ( acceptable error rates), examples for file DO of grossing, other performance such as instrument programming/maintenance Written quiz, policies procedures, troubleshooting( problem solving documentation) Continuing education participation records Joelle Weaver MAOM, HTL (ASCP) QIHC From: sm...@msn.com To: amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Wed, 9 Apr 2014 11:10:18 + Subject: RE: [Histonet] RE: competency form CC: We were recently dinged by CAP for our competency assessments in all areas. While that's no longer my immediate responsibility, I would love to be able to assist the lab manager with some information so we can tweek our assessments if you all wouldn't mind sharing with me as well. Thanks a bunch. Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: amber.mcken...@gastrodocs.net To: ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Tue, 8 Apr 2014 21:17:44 + CC: Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto:ronald.hous...@nationwidechildrens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
The NSH does have some good basic forms that may help in getting your organization's forms together. I would probably evolve them from those into what fits in with your situation. There have been a couple of webinars in the past dealing with competency in histology and meeting requirements under CLIA and CAP. I think that it is a recurring topic that comes up since competency crosses over into many other arenas such as personnel staffing, education training, compliance, test performance( reliability/reproducibility), errors and process improvements, and potentially other areas that supervisors and managers juggle every day. Joelle Weaver MAOM, HTL (ASCP) QIHC From: sm...@msn.com To: foreig...@gmail.com; sad...@wisc.edu Date: Wed, 9 Apr 2014 12:24:36 + Subject: RE: [Histonet] RE: competency form CC: histonet@lists.utsouthwestern.edu; ronald.hous...@nationwidechildrens.org Thanks for the reference Patrick! Date: Wed, 9 Apr 2014 08:22:34 -0400 From: foreig...@gmail.com To: sad...@wisc.edu Subject: Re: [Histonet] RE: competency form CC: histonet@lists.utsouthwestern.edu; ronald.hous...@nationwidechildrens.org We based ours off the Michigan Society of Histotechnologist's Competency Assessment Handbook (available on their website for a nominal fee). We took some of their forms/ideas and modified them for our use. Patrick Laurie(HT)ASCP QIHC Histology Manager Celligent Diagnostics, LLC 101 East W.T. Harris Blvd | Suite 1212 | Charlotte, NC 28262 Work: 704-970-3300 Cell: 704-266-0869 On Wed, Apr 9, 2014 at 8:19 AM, Sally Ann Drew sad...@wisc.edu wrote: I don't know if it's reasonable to share with all of us, but I bet there are a lot of us that would be interested in how others are approaching these topics. I doubt there are that many workshops on the issue-or have there been teleconferences maybe that cover the subject? _Sally Sally Ann Drew,MT(ASCP) UW SMPH-Dept. of Pathology TRIP/TSB-TRIP Lab Manager CSC, K4/435 608.265.4378 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Amber McKenzie Sent: Tuesday, April 08, 2014 4:18 PM To: Houston, Ronald; Histonet Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614-722-2899 ronald.hous...@nationwidechildrens.orgmailto: ronald.houston@nationwidechild rens.org www.NationwideChildrens.orghttp://www.nationwidechildrens.org/ One person with passion is better than forty people merely interested. ~ E.M. Forster ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task documented along with any corrective action necessary; the correlation of proficiency tests, educational assessments and performance reviews for technical staff; daily evaluations from the pathologists concerning staining, microtomy and grossing; and educational training documentation. We had no idea with all pieces of this documentation that we were anticipated to have more. The form for DO of each task was not detailed enough (despite listing each task and proficiency or corrective action of each task) according to the inspectors. I was hoping someone could share a form so as to assist us in seeing what holes there are in our form. While this DO form is definitely not our only form, the inspectors specifically commented on this one. If anyone can assist, it would be helpful. Thank you, Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: joellewea...@hotmail.com To: sm...@msn.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form Date: Wed, 9 Apr 2014 12:26:47 + Is the question that Ronnie posed yesterday requesting justification of the need and extent of competency documentation for histology, or is it just a form needed? The general checklist pretty much sums up the necessity for doing, and required elements to me- GEN. 55500 and CLIA. Maybe I am not understanding? As for a form, I would expect that the specific items on any forms will vary by your personnel and by the testing and processes you perform. What I did to document initial training and competency was a make a summary checklist for each bench with tasks and direct observations DO for initial training documentation of satisfactory performance before patient testing. I just put all those checklists together in a summary table for each person. High complexity; such as grossing, IHC, FISH scoring get more attention and documentation, the waived tests, you have more discretion,- but I thought it easier to do everything about the same. I have not been inspected on this document yet ( so can't say if CAP will have issues with it- but will know soon...) but here is basically what I did to meet GEN.55500 or the main parts; Defined how competency is monitored- method and frequency ( just included as part of the competency SOP) Orientation and initial training documentation in a checklist for general lab, safety Training checklist on each technical bench, instrument, major procedure PT records and performance/results DO- a practical assessment ( block, slides, stains), for the assessment of previously analyzed specimens, and a PI feedback checklist for the technical from this audit of issues- how/what to improve Check off in performing QC, calibration, patient ID procedures ( acceptable error rates), examples for file DO of grossing, other performance such as instrument programming/maintenance Written quiz, policies procedures, troubleshooting( problem solving documentation) Continuing education participation records Joelle Weaver MAOM, HTL (ASCP) QIHC From: sm...@msn.com To: amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Wed, 9 Apr 2014 11:10:18 + Subject: RE: [Histonet] RE: competency form CC: We were recently dinged by CAP for our competency assessments in all areas. While that's no longer my immediate responsibility, I would love to be able to assist the lab manager with some information so we can tweek our assessments if you all wouldn't mind sharing with me as well. Thanks a bunch. Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: amber.mcken...@gastrodocs.net To: ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Tue, 8 Apr 2014 21:17:44 + CC: Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone please share the competency form(s) they are using to satisfy CAP? I am having problems convincing our QA/Compliance folks of the differences between testing in AP compared to the other lab disciplines, who do read our test results Thanks Ronnie Houston, MS HT(ASCP)QIHC Anatomic Pathology Manager ChildLab, a Division of Nationwide Children's Hospital www.childlab.com 700 Children's Drive Columbus, OH 43205 (P) 614-722-5450 (F) 614
RE: [Histonet] RE: competency form
True there is inspector variation. Maybe we should all pool our resources and see what we can come up with collaboratively? It is great to know what the CAP feedback has been so we can all fill in any gaps. Joelle Weaver MAOM, HTL (ASCP) QIHC From: trathbo...@somerset-healthcare.com To: sm...@msn.com; joellewea...@hotmail.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form Date: Wed, 9 Apr 2014 13:04:17 + CAP inspectors may have opinions which differ from our own, and their interpretation of standards may also be different. Have you challenged this deficiency with CAP? -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Sheila Haas Sent: Wednesday, April 09, 2014 8:52 AM To: joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task documented along with any corrective action necessary; the correlation of proficiency tests, educational assessments and performance reviews for technical staff; daily evaluations from the pathologists concerning staining, microtomy and grossing; and educational training documentation. We had no idea with all pieces of this documentation that we were anticipated to have more. The form for DO of each task was not detailed enough (despite listing each task and proficiency or corrective action of each task) according to the inspectors. I was hoping someone could share a form so as to assist us in seeing what holes there are in our form. While this DO form is definitely not our only form, the inspectors specifically commented on this one. If anyone can assist, it would be helpful. Thank you, Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: joellewea...@hotmail.com To: sm...@msn.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form Date: Wed, 9 Apr 2014 12:26:47 + Is the question that Ronnie posed yesterday requesting justification of the need and extent of competency documentation for histology, or is it just a form needed? The general checklist pretty much sums up the necessity for doing, and required elements to me- GEN. 55500 and CLIA. Maybe I am not understanding? As for a form, I would expect that the specific items on any forms will vary by your personnel and by the testing and processes you perform. What I did to document initial training and competency was a make a summary checklist for each bench with tasks and direct observations DO for initial training documentation of satisfactory performance before patient testing. I just put all those checklists together in a summary table for each person. High complexity; such as grossing, IHC, FISH scoring get more attention and documentation, the waived tests, you have more discretion,- but I thought it easier to do everything about the same. I have not been inspected on this document yet ( so can't say if CAP will have issues with it- but will know soon...) but here is basically what I did to meet GEN.55500 or the main parts; Defined how competency is monitored- method and frequency ( just included as part of the competency SOP) Orientation and initial training documentation in a checklist for general lab, safety Training checklist on each technical bench, instrument, major procedure PT records and performance/results DO- a practical assessment ( block, slides, stains), for the assessment of previously analyzed specimens, and a PI feedback checklist for the technical from this audit of issues- how/what to improve Check off in performing QC, calibration, patient ID procedures ( acceptable error rates), examples for file DO of grossing, other performance such as instrument programming/maintenance Written quiz, policies procedures, troubleshooting( problem solving documentation) Continuing education participation records Joelle Weaver MAOM, HTL (ASCP) QIHC From: sm...@msn.com To: amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Wed, 9 Apr 2014 11:10:18 + Subject: RE: [Histonet] RE: competency form CC: We were recently dinged by CAP for our competency assessments in all areas. While that's no longer my immediate responsibility, I would love to be able to assist the lab manager with some information so we can tweek our assessments if you all wouldn't mind sharing with me as well. Thanks a bunch. Sheila Haas MicroPath Laboratories, Inc. Quality Assurance
RE: [Histonet] RE: competency form
CAP inspectors may have opinions which differ from our own, and their interpretation of standards may also be different. Have you challenged this deficiency with CAP? -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Sheila Haas Sent: Wednesday, April 09, 2014 8:52 AM To: joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task documented along with any corrective action necessary; the correlation of proficiency tests, educational assessments and performance reviews for technical staff; daily evaluations from the pathologists concerning staining, microtomy and grossing; and educational training documentation. We had no idea with all pieces of this documentation that we were anticipated to have more. The form for DO of each task was not detailed enough (despite listing each task and proficiency or corrective action of each task) according to the inspectors. I was hoping someone could share a form so as to assist us in seeing what holes there are in our form. While this DO form is definitely not our only form, the inspectors specifically commented on this one. If anyone can assist, it would be helpful. Thank you, Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: joellewea...@hotmail.com To: sm...@msn.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form Date: Wed, 9 Apr 2014 12:26:47 + Is the question that Ronnie posed yesterday requesting justification of the need and extent of competency documentation for histology, or is it just a form needed? The general checklist pretty much sums up the necessity for doing, and required elements to me- GEN. 55500 and CLIA. Maybe I am not understanding? As for a form, I would expect that the specific items on any forms will vary by your personnel and by the testing and processes you perform. What I did to document initial training and competency was a make a summary checklist for each bench with tasks and direct observations DO for initial training documentation of satisfactory performance before patient testing. I just put all those checklists together in a summary table for each person. High complexity; such as grossing, IHC, FISH scoring get more attention and documentation, the waived tests, you have more discretion,- but I thought it easier to do everything about the same. I have not been inspected on this document yet ( so can't say if CAP will have issues with it- but will know soon...) but here is basically what I did to meet GEN.55500 or the main parts; Defined how competency is monitored- method and frequency ( just included as part of the competency SOP) Orientation and initial training documentation in a checklist for general lab, safety Training checklist on each technical bench, instrument, major procedure PT records and performance/results DO- a practical assessment ( block, slides, stains), for the assessment of previously analyzed specimens, and a PI feedback checklist for the technical from this audit of issues- how/what to improve Check off in performing QC, calibration, patient ID procedures ( acceptable error rates), examples for file DO of grossing, other performance such as instrument programming/maintenance Written quiz, policies procedures, troubleshooting( problem solving documentation) Continuing education participation records Joelle Weaver MAOM, HTL (ASCP) QIHC From: sm...@msn.com To: amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Wed, 9 Apr 2014 11:10:18 + Subject: RE: [Histonet] RE: competency form CC: We were recently dinged by CAP for our competency assessments in all areas. While that's no longer my immediate responsibility, I would love to be able to assist the lab manager with some information so we can tweek our assessments if you all wouldn't mind sharing with me as well. Thanks a bunch. Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: amber.mcken...@gastrodocs.net To: ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Date: Tue, 8 Apr 2014 21:17:44 + CC: Subject: [Histonet] RE: competency form Can you pass it on to me as well? I'd love to compare what I've got to what someone else is doing. Thanks, Amber -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Houston, Ronald Sent: Tuesday, April 08, 2014 2:37 PM To: Histonet Subject: [Histonet] competency form Can someone
Re: [Histonet] RE: competency form
So I went to one of the CAP webinars regarding competency And when I asked what about histology there were complete silence on the other end of the line and than they said there was nothing for histology. At our site they want something for very division so I put together a basic form and use it for the multitude of major tasks in histology. We are not getting inspeted until next year but from what I hear CAP is planning on making major changes for the pathology protion of CAP's checklist, what that means I do not know. Since CAP canot give us concrete rules for histology I think that anything a lab does is better than nothing, and shows initiative on their part to meet CAP's requirements. Since this is a peer review the inspector can suggest alternatives but cannot say you are in violation because the do not like your form. Just my thoughts S. Paturzo TJUH ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
Re: [Histonet] RE: competency form
Well, it would be nice if that was the case but we ended up with a deficiency. It was rather disappointing given our overall documentation. Sent from my iPhone On Apr 9, 2014, at 4:37 PM, Sue suetp...@comcast.net wrote: So I went to one of the CAP webinars regarding competency And when I asked what about histology there were complete silence on the other end of the line and than they said there was nothing for histology. At our site they want something for very division so I put together a basic form and use it for the multitude of major tasks in histology. We are not getting inspeted until next year but from what I hear CAP is planning on making major changes for the pathology protion of CAP's checklist, what that means I do not know. Since CAP canot give us concrete rules for histology I think that anything a lab does is better than nothing, and shows initiative on their part to meet CAP's requirements. Since this is a peer review the inspector can suggest alternatives but cannot say you are in violation because the do not like your form. Just my thoughts S. Paturzo TJUH ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
I appreciate your thoughts. True, seems like they couldn't be too specific in their requirements if they cannot list specifically what they require ( when you specifically ask), what a sentence! We will all find out if that is the case or not soon enough. Anyhow, I just want to agree with you that all the signs seem to be that there will be tightening, based on their magazine articles and web site postings, etc; seems like validation verification, competency, PT ( interlaboratory correlation) will be at the top of the list...stay tuned. Joelle Weaver MAOM, HTL (ASCP) QIHC Date: Wed, 9 Apr 2014 20:37:55 + From: suetp...@comcast.net To: joellewea...@hotmail.com CC: trathbo...@somerset-healthcare.com; sm...@msn.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: Re: [Histonet] RE: competency form So I went to one of the CAP webinars regarding competency And when I asked what about histology there were complete silence on the other end of the line and than they said there was nothing for histology. At our site they want something for very division so I put together a basic form and use it for the multitude of major tasks in histology. We are not getting inspeted until next year but from what I hear CAP is planning on making major changes for the pathology protion of CAP's checklist, what that means I do not know. Since CAP canot give us concrete rules for histology I think that anything a lab does is better than nothing, and shows initiative on their part to meet CAP's requirements. Since this is a peer review the inspector can suggest alternatives but cannot say you are in violation because the do not like your form. Just my thoughts S. Paturzo TJUH ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: competency form
There is a great need for standardization in histotechnology, from forms, policies, procedures/methods to controls processes and protocols. Hope NSH is working with ASCP and CAP to make this happen. MSgt Ian R Bernard, HT(ASCP), MSHA-UAB Anatomic Pathology Lab Manager USAF- Active Duty 210-687-7540 Cell ibern...@uab.edu ian.bern...@comcast.net -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of joelle weaver Sent: Wednesday, April 09, 2014 7:09 AM To: Rathborne, Toni; 'Sheila Haas'; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form True there is inspector variation. Maybe we should all pool our resources and see what we can come up with collaboratively? It is great to know what the CAP feedback has been so we can all fill in any gaps. Joelle Weaver MAOM, HTL (ASCP) QIHC From: trathbo...@somerset-healthcare.com To: sm...@msn.com; joellewea...@hotmail.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form Date: Wed, 9 Apr 2014 13:04:17 + CAP inspectors may have opinions which differ from our own, and their interpretation of standards may also be different. Have you challenged this deficiency with CAP? -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Sheila Haas Sent: Wednesday, April 09, 2014 8:52 AM To: joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task documented along with any corrective action necessary; the correlation of proficiency tests, educational assessments and performance reviews for technical staff; daily evaluations from the pathologists concerning staining, microtomy and grossing; and educational training documentation. We had no idea with all pieces of this documentation that we were anticipated to have more. The form for DO of each task was not detailed enough (despite listing each task and proficiency or corrective action of each task) according to the inspectors. I was hoping someone could share a form so as to assist us in seeing what holes there are in our form. While this DO form is definitely not our only form, the inspectors specifically commented on this one. If anyone can assist, it would be helpful. Thank you, Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: joellewea...@hotmail.com To: sm...@msn.com; amber.mcken...@gastrodocs.net; ronald.hous...@nationwidechildrens.org; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] RE: competency form Date: Wed, 9 Apr 2014 12:26:47 + Is the question that Ronnie posed yesterday requesting justification of the need and extent of competency documentation for histology, or is it just a form needed? The general checklist pretty much sums up the necessity for doing, and required elements to me- GEN. 55500 and CLIA. Maybe I am not understanding? As for a form, I would expect that the specific items on any forms will vary by your personnel and by the testing and processes you perform. What I did to document initial training and competency was a make a summary checklist for each bench with tasks and direct observations DO for initial training documentation of satisfactory performance before patient testing. I just put all those checklists together in a summary table for each person. High complexity; such as grossing, IHC, FISH scoring get more attention and documentation, the waived tests, you have more discretion,- but I thought it easier to do everything about the same. I have not been inspected on this document yet ( so can't say if CAP will have issues with it- but will know soon...) but here is basically what I did to meet GEN.55500 or the main parts; Defined how competency is monitored- method and frequency ( just included as part of the competency SOP) Orientation and initial training documentation in a checklist for general lab, safety Training checklist on each technical bench, instrument, major procedure PT records and performance/results DO- a practical assessment ( block, slides, stains), for the assessment of previously analyzed specimens, and a PI feedback checklist for the technical from this audit of issues- how/what to improve Check off in performing QC, calibration, patient ID procedures ( acceptable error rates), examples for file DO of grossing, other performance such as instrument programming/maintenance Written quiz, policies procedures, troubleshooting( problem solving documentation) Continuing education
RE: [Histonet] RE: competency form- Inspector Perspective.
I recently had the great honor to serve as a CAP inspector in Arizona. The lab we inspected will be accredited. Lest we forget as inspectors or future inspectors, I hope the below perspective illuminates the purpose of the CAP inspection and helps preserve the integrity of the program if adhered to. As inspectors, we are trained to be thorough but to simultaneously use objective judgment i.e. there may be several ways to meet the intent of the question and that we must review all pertinent documentation and then determine if the process meets the intent of the requirement. Keeping in mind that the purpose of CAP inspection is not punitive but quality laboratory improvement to fulfill the regulatory purpose of the inspection (CLIA). Our focus should be, in the interest of time and thoroughness major compliance issue rather than nitpick. This helps us maintain professionalism and preserve the peer-review nature of the program. So what is it that constitutes compliance? Per CAP: - One, that the laboratory has defined a policy, a procedure, or a plan of the three P's for how they are going to do things in the lab. - Secondly, actual practices that matches those three P's. - Finally, documentation to support the fact that practice has indeed matched policies and procedures. So what is a deficiency? Per CAP: A deficiency means that the lab did not meet the intent of the checklist item. It's not the wording; it's not the specifics. It is the intent. If any of the three above criteria are not yet met, we should cite a deficiency We are admonished to remember that there may be many ways to accomplish an objective. The lab may not do things exactly the way that your lab does, but may still be meeting the intent of the requirement(s). Citing a laboratory for not doing it the way we do it is a common inspector error. Per CAP, partial compliance is the following: If there is partial compliance (e.g., some records are inconsistent, one bottle of reagent was not labeled completely, a few temperatures were not recorded, etc.), you must judge whether the degree of non-compliance is likely to have adverse effects on test accuracy, patient care, or worker safety. Also, determine if the lab staff was aware of the inconsistency and if corrective actions were performed. If adverse effects are likely or if there are definite patterns (e.g., missing temperatures only on weekends) without corrective actions only then we must cite a deficiency. Bottom-line, If you feel you were incorrectly cited since you met the intent of the question, you should appeal to CAP. It is an inspected lab's right. If a phase 11 deficiency, submit your evidence of compliance and the Lab Accreditation Committee will either overrule or sustain. I suspect they will overrule. Just saying, but based upon just what you described, it sounds like you all met the intent of the question. MSgt Ian R Bernard, HT(ASCP), MSHA-UAB Anatomic Pathology Lab Manager USAF- Active Duty ibern...@uab.edu ian.bern...@comcast.net -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Rathborne, Toni Sent: Wednesday, April 09, 2014 7:04 AM To: 'Sheila Haas'; joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form CAP inspectors may have opinions which differ from our own, and their interpretation of standards may also be different. Have you challenged this deficiency with CAP? -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Sheila Haas Sent: Wednesday, April 09, 2014 8:52 AM To: joelle weaver; Amber McKenzie; Houston, Ronald; Histonet Subject: RE: [Histonet] RE: competency form What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task documented along with any corrective action necessary; the correlation of proficiency tests, educational assessments and performance reviews for technical staff; daily evaluations from the pathologists concerning staining, microtomy and grossing; and educational training documentation. We had no idea with all pieces of this documentation that we were anticipated to have more. The form for DO of each task was not detailed enough (despite listing each task and proficiency or corrective action of each task) according to the inspectors. I was hoping someone could share a form so as to assist us in seeing what holes there are in our form. While this DO form is definitely not our only form, the inspectors specifically commented on this one. If anyone can assist, it would be helpful. Thank you, Sheila Haas MicroPath Laboratories, Inc. Quality Assurance Coordinator From: joellewea...@hotmail.com To: sm...@msn.com; amber.mcken...@gastrodocs.net
