[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: victor <@t> pathology.washington.edu
> From: BSullivan <@t> shorememorial.org
> Date: Thu, 23 Dec 2010 07:53:22 -0500
> Subject: Re: [Histonet] CAP Question regarding procedure manual
> CC: Histonet <@t> lists.utsouthwestern.edu; histonet-bounces <@t> 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                                                 
>              <victor <@t> pathology                                             
>              .washington.edu>                                           To 
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>              ern.edu                                                       
>                                                                    Subject 
>                                        [Histonet] CAP Question regarding   
>              12/22/2010 06:16          procedure manual                    
>              PM                                                            
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> 
> 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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