[Histonet] CAP Question regarding procedure manual

[BSullivan <@t> shorememorial.org]

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.cac <@t> hot                                             
             mail.com>                                                  To 
                                       <bsullivan <@t> shorememorial.org>,      
             12/23/2010 08:26          Victor Tobias                       
             AM                        <victor <@t> pathology.washington.edu>   
                                                                        cc 
                                       histonet                            
                                       <histonet <@t> lists.utsouthwestern.edu> 
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                                       <histonet-bounces <@t> 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: 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
> Sent by: Histonet
> histonet-bounces@ <Histonet <@t> 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
> victor <@t> pathology.washington.edu
> 206-598-2792
> 206-598-7659 Fax
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