[Histonet] Techs Documenting Knowing Procedure Manual

Joe Nocito jnocito <@t> satx.rr.com
Fri Aug 3 09:13:18 CDT 2007

Let me stir the pot (as only I can). Some people read too much into 
questions and therefore create more work than necessary. All that is 
required is that the techs review the procedures. Like Rene, I have one 
sheet in front of every manual that they sign off on. During my CAP 
inspection this year, one inspector insisted that I create a procedure for 
every specimen I gross. I told her (and showed her) tat I had 4 grossing 
manuals to go by. She insisted that I make policies. I told her that wasn't 
going to happen. She told me she had to do that. Point of the story: a 
signature page in front of the manuals is sufficient, don't create more work 
than you need to.

----- Original Message ----- 
From: "Lee & Peggy Wenk" <lpwenk <@t> sbcglobal.net>
To: <histonet <@t> lists.utsouthwestern.edu>
Sent: Friday, August 03, 2007 4:59 AM
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 
> personnel
> are knowledgeable about the contents of procedure manuals relevant to the
> 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 on
> each procedure. That having one sheet in the front of the staining manual
> that says "I know and understand and will follow all the procedures in 
> this
> manual" is not acceptable.
> However, there is no comment either way after the CAP checklist question.
> 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 Laboratory
> Services; Approved Guideline-Third Edition. NCCLS document GP26-A3
> Can someone point me in the right direction, or have I been misinformed 
> all
> 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? 
> Is
> one sheet OK, or do should there be a list of all the procedures, and they
> 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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