[Histonet] Techs Documenting Knowing Procedure Manual

Janice Mahoney jmahoney <@t> alegent.org
Fri Aug 3 10:35:25 CDT 2007

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

>>> "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
every specimen I gross. I told her (and showed her) tat I had 4
manuals to go by. She insisted that I make policies. I told her that
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
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
> scope of their testing activities?
> I have been told as several NSH workshops, and also talking with
> 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
> that says "I know and understand and will follow all the procedures
> this
> 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
> 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
> 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
> Is
> 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
> employees reading the procedures, or just have one sheet in the
> Thanks in advance for input.
> Peggy A. Wenk, HTL(ASCP)SLS
> William Beaumont Hospital
> Royal Oak, MI 48073
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