[SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - Email found in subject

Thu Dec 23 10:49:53 CST 2010

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: RCazares <@t> schosp.org
> To: wdesalvo.cac <@t> 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-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of WILLIAM DESALVO
> Sent: Thursday, December 23, 2010 7:27 AM
> To: bsullivan <@t> shorememorial.org; Victor Tobias
> Cc: histonet; histonet-bounces <@t> 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: 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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