[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: jellin <@t> yumaregional.org 


-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu
[mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of WILLIAM
DESALVO
Sent: Wednesday, December 22, 2010 4:46 PM
To: victor <@t> 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: victor <@t> pathology.washington.edu
> To: Histonet <@t> 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
> victor <@t> pathology.washington.edu
> 206-598-2792
> 206-598-7659 Fax
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