[Histonet] Histotechnology Laboratory Procedure Assignment

Terri Braud tbraud <@t> holyredeemer.com
Fri Sep 22 15:31:39 CDT 2006

in answer to your questions...

1. For the whole lab, CAP(College of American Pathologists), JCAHO (Joint Commission for Accreditation of Healthcare Organizations) and AABB (American Assoc of Blood Banks)
Procedures must be reviewed annually, divided into sections so that a portion is reviewed every month.  New procedures must be reviewed by the Chief Pathologist, and thereafter, by his designee (in this case, the Anatomic Pathology Supervisor)  This is a CAP reg.  If a new Medical Director is hired, then he/she must review and sign all lab procedures within a reasonable amount of time.

2. We have 322 Histology related procedures.  Those pertaining to all divisions of the lab (such as retention of records, HIPPA rules, etc.) are in the Gen Lab Manual in addition to all Safety Procedures that are in a General Lab Safety manual  Specific to the AP department, we have 4 manuals.  The General Anatomic Pathology manual, which covers Histology and Cytology, the Immunohistochemistry Manual, the Special Stains Manual, and the Quality Assurance and Quality Control Manual. In addition to that, we keep a manual of MSDS (Material Safety Data Sheets) for every chemical in use in our department.

3.  New employees must show review of the manuals by signature, in addition to signing a proficiency qualification for all procedures they are expected to routinely perform.  They must be signed off on any procedure by a supervising technician before performing the procedure independently. After that, certain procedures are selectively tested for annual competancy for the annual review.  Also, any technician performing tissue gross dissections must have a special annual gross competancy check by the chief pathologist for every type of specimen that is defined in the non pathologist grossing policy.  These cases are directly observed, documented, and signed off on by the Chief Pathologist in order for them to perform gross dissections.

4. The AP Supervisor is responsible for the creation of new procedures as requested or as needed.  They must be written in NCCLS (National Committee for Clinical Laboratory Standards)approved format, and they must be approved by the Chief Pathologist and then signed off by all technicians before being put into place. 

I hope this helps.
Terri Braud
Terri L. Braud, HT(ASCP)
Anatomic Pathology Supv.
Medical Laboratory 
Holy Redeemer Hospital and Medical Center
(215) 938-3689

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu
[mailto:histonet-bounces <@t> lists.utsouthwestern.edu]On Behalf Of
Scheherazade Humphrey
Sent: Friday, September 22, 2006 11:13 AM
To: histonet <@t> lists.utsouthwestern.edu
Subject: [Histonet] Histotechnology Laboratory Procedure Assignment

Hello Everyone,
  My name is Scheherazade Humphrey and I am currently a student at Argosy University in the Twin Cities. I was asked by my instructor to post a listserve to get possible answers and help on one of my assignments. If any one is able to answer any of  the following questions, that would be greatly appreciated. Thank you. The following questions are :
  1. What accreditation does your laboratory have? Who is responsible for reviewing your lab procedures? How often is it done?
  2. About how many histotechnology related procedures exist in your laboratory? How are they organized? Where are they kept?
  3. What is the policy for new employees in relation to learning the laboratory procedures?
  4. Who is responsible for creating new procedures when needed? What is the process?
  Thank you for participating in my Questionnaire for my Histotechnology Laboratory Procedure Assignment. 

Scheherazade H. 
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