[Histonet] Techs Documenting Knowing Procedure Manual

[Janice Mahoney]

I agree with Joe.  I have been an inspector and been inspected many
times over the years.  I think the process Joe proposes  meets CAP.  The
Pathologist or his/her designee must sign each procedure annually.  The
only other thing I look for is that each new or revised procedure is
signed off by each person using that procedure.  
So, new employees just need to sign the manual.  Everyone must sign off
on new or revised procedures.  If people want to do more, that is their
choice, but not required.
Jan Mahoney
Alegent Health
Omaha

>>> "Joe Nocito" <jnocito <@t> satx.rr.com> 08/03/2007 9:13 AM >>>
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.

JTT
----- 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
>
>
> _______________________________________________
> Histonet mailing list
> Histonet <@t> lists.utsouthwestern.edu 
> http://lists.utsouthwestern.edu/mailman/listinfo/histonet 


_______________________________________________
Histonet mailing list
Histonet <@t> lists.utsouthwestern.edu 
http://lists.utsouthwestern.edu/mailman/listinfo/histonet