[SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - Email found in subject

Mon Dec 27 14:28:24 CST 2010

Do others document separately the original creation, training, competency, 
implementation of procedures/processes and then continual yearly training, 
competency and review of those processes? Are you using a Quality 
Management System? How about Electronic system to manage?

Yes, to all of those. We document original training and then all 
competencies are part of their yearly eval. We also have the QMS 
electronic policy/procedure Data base that sends each individual reminders 
when they need to read a update or sign off on the yearly requirement that 
they have read and understand the material. 

Kim Donadio 
Pathology Supervisor
Baptist Hospital
1000 W Moreno St.
Pensacola FL 32501
Phone (850) 469-7718
Fax (850) 434-4996

WILLIAM DESALVO <wdesalvo.cac <@t> hotmail.com> 
Sent by: histonet-bounces <@t> lists.utsouthwestern.edu
12/23/2010 10:49 AM

To
<rcazares <@t> schosp.org>, histonet <histonet <@t> lists.utsouthwestern.edu>
cc

Subject
RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure manual - 
Email found in subject

Thanks, I am aware of Peggy's form. We have similar hard copy forms now, 
but we are moving to an electronic system. It will be much more manageable 
for 125 employees.

When you state in your form the employee is competent, do you have 
documentation to support that there was a competency evaluation? We only 
state the employee has read and understands. We have separate 
documentation for training and competency.

I love this type of discussion string. There are so many different 
processes out in Histoland.

Do others document separately the original creation, training, competency, 
implementation of procedures/processes and then continual yearly training, 
competency and review of those processes? Are you using a Quality 
Management System? How about Electronic system to manage?

William DeSalvo, B.S., HTL(ASCP)

> From: RCazares <@t> schosp.org
> To: wdesalvo.cac <@t> hotmail.com
> Date: Thu, 23 Dec 2010 10:17:48 -0600
> Subject: RE: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure 
manual - Email found in subject
> 
> Hello histonetters,
> 
> When I implement a new procedure in my lab, besides the routine yearly 
sign-off sheet that accompanies the procedure, there an additional sheet 
that states
> 
> " The following employees have reviewed this procedure and by signing 
below are acknowledging that they understand and are competent in 
performing the procedure:"
> 
> Below that statement is a box with signature and date lines for all the 
employees using this procedure to sign. This makes each employee 
responsible for reading and understanding the procedure. This I got from 
one of Peggy Wenk's workshops (Thanks Peggy!!). I can send a copy to 
anyone who'd like one, just contact me directly.
> 
> 
> Ruth Cazares, HT (ASCP)
> Histology Supervisor
> Department of Pathology
> Swedish Covenant Hospital
> Chicago, IL
> 
> 
> 
> 
> 
> -----Original Message-----
> From: histonet-bounces <@t> lists.utsouthwestern.edu 
[mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of WILLIAM 
DESALVO
> Sent: Thursday, December 23, 2010 7:27 AM
> To: bsullivan <@t> shorememorial.org; Victor Tobias
> Cc: histonet; histonet-bounces <@t> lists.utsouthwestern.edu
> Subject: [SPAM-HC] - RE: [Histonet] CAP Question regarding procedure 
manual - Email found in subject
> 
> 
> Beatrice,
> How do you show proof to CAP that your employees that use the procedures 
and perform the tasks described in the procedures have reviewed and 
understand the procedure when there is a new one during your cycle year 
and before it is implemented?
> 
> CAP has changed the way they inspect and they are now looking for how 
whether the employees performing a task described in the procedure 
understands the procedure and is performing exactly as the procedure 
describes. They are not as concerned that the Supervisor and management 
knows about the procedures, they want to see how informed, trained and 
competent the bench employee is.
> 
> William DeSalvo, B.S., HTL(ASCP)
> 
> 
> 
> 
> 
> > To: victor <@t> pathology.washington.edu
> > From: BSullivan <@t> shorememorial.org
> > Date: Thu, 23 Dec 2010 07:53:22 -0500
> > Subject: Re: [Histonet] CAP Question regarding procedure manual
> > CC: Histonet <@t> lists.utsouthwestern.edu; 
histonet-bounces <@t> lists.utsouthwestern.edu
> >
> > Victor,
> > To my knowledge all you need is proof that the staff reviewed the 
manuals.
> > We accomplish this by a sign off sheet in the front of each manual we 
use.
> > The Supervisor, or designee, needs to review and sign off on each 
procedure
> > in each manual.
> >
> > Beatrice Sullivan, HT(A.S.C.P.) HTL , AAS, CLSP(N.C.A.)
> > AP Supervisor
> > Shore Memorial Hospital
> > 609-653-3590
> >
> >
> > Speak only well of people and you need never whisper
> >
> >
> >
> > Victor Tobias
> > <victor <@t> pathology
> > .washington.edu> To
> > Sent by: Histonet
> > histonet-bounces@ <Histonet <@t> lists.utsouthwestern.edu>
> > lists.utsouthwest cc
> > ern.edu
> > Subject
> > [Histonet] CAP Question regarding
> > 12/22/2010 06:16 procedure manual
> > PM
> >
> >
> >
> >
> >
> >
> >
> >
> >
> > Is there a requirement to have a signature of every staff member on a
> > procedure if they perform that procedure in a manual? Wouldn't one
> > signature on a cover page suffice that you have read and understand 
what
> > is in the manual?
> >
> > Victor
> >
> > --
> > Victor Tobias
> > Clinical Applications Analyst
> > University of Washington Medical Center
> > Dept of Pathology Room BB220
> > 1959 NE Pacific
> > Seattle, WA 98195
> > victor <@t> pathology.washington.edu
> > 206-598-2792
> > 206-598-7659 Fax
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