[Histonet] Techs Documenting Knowing Procedure Manual

Charles.Embrey Charles.Embrey <@t> carle.com
Fri Aug 3 08:12:29 CDT 2007

Anthony,  Your response is about lab director signing off each year but
Peggy is asking about ANP.20150 and it has the comment "The form of this
system is at the discretion of the Laboratory Director."  I have a
signoff page that lists all policies and procedures for each employee
and keep it in their file.  Each employee initials off on the reviewed
item and I have never had a problem with any CAP inspector accepting
that form in 25 years of inspections.


-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu
[mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Anthony
F. Boris
Sent: Friday, August 03, 2007 7:54 AM
To: histonet <@t> lists.utsouthwestern.edu
Subject: RE: [Histonet] Techs Documenting Knowing Procedure Manual

Hi Peggy, 
Copied below is a question from the CAP website.  Note in the last 2
lines of the "Note" paragraph where it talks about signatures.   One
signature is not sufficient on a main page, but if you list each
procedure on one page, you can initial each procedure on that one page.
It wants multiple signatures.  

The intent seems to make sure each document is reviewed, but how does
allowing a main page where you can sign your name 50 times ensure that
you have read the manual?  We have gone to signing each individual
procedure, we feel that this is what will be required in the future.

Good Luck,

ANP.03776             Phase II	N/A   YES   NO

Is there documentation of at least annual review of all policies and
procedures in the anatomic pathology section by the current laboratory
director or designee?

NOTE:  The director must ensure that the collection of policies and
procedures is complete, current, and has been thoroughly reviewed by a
knowledgeable person.  Technical approaches must be scientifically valid
and clinically relevant.  To minimize the burden on the laboratory and
reviewer(s), it is suggested that a schedule be developed whereby
roughly 1/12 of all procedures are reviewed monthly.  Paper/electronic
signature review must be at the level of each procedure, or as multiple
signatures on a listing of named procedures.  A single signature on a
Title Page or Index of all procedures is not sufficient documentation
that each procedure has been carefully reviewed.  Signature or initials
on each page of a procedure is not required.

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu on behalf of Lee & Peggy
Sent: Fri 8/3/2007 5:59 AM
To: histonet <@t> lists.utsouthwestern.edu
Subject: [Histonet] Techs Documenting Knowing Procedure Manual
Need some help interpreting a CAP check list question.

ANP.06440  Does the laboratory have a system documenting that all
are knowledgeable about the contents of procedure manuals relevant to
scope of their testing activities?

I have been told as several NSH workshops, and also talking with various
histotechs who have been inspected by CAP, that techs have to sign off
each procedure. That having one sheet in the front of the staining
that says "I know and understand and will follow all the procedures in
manual" is not acceptable.

However, there is no comment either way after the CAP checklist
I've looked up the two NCCLS regs, and can't find it there either (but I
also fall asleep trying to read the NCCLS regs). 
REFERENCES: 1) NCCLS. A Quality Management System Model for Health Care;
Approved Guideline-Second Edition. NCCLS document HS1-A2 
2) NCCLS. Application of a Quality Management System Model for
Services; Approved Guideline-Third Edition. NCCLS document GP26-A3 

Can someone point me in the right direction, or have I been misinformed
these years?

I know employees don't have to sign off every year, only the director. I
know employees have to sign off on new or changed procedures.

But what do you do with a new employee, who has to read every procedure?
one sheet OK, or do should there be a list of all the procedures, and
sign off on each one and date it? 

What if I'm inspecting a lab, and see that they don't have any record of
employees reading the procedures, or just have one sheet in the front? 

Thanks in advance for input.

Peggy A. Wenk, HTL(ASCP)SLS
William Beaumont Hospital
Royal Oak, MI 48073

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