[Histonet] RE: competency form

Wed Apr 9 08:04:17 CDT 2014

CAP inspectors may have opinions which differ from our own, and their interpretation of standards may also be different. Have you challenged this deficiency with CAP? 

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Sheila Haas
Sent: Wednesday, April 09, 2014 8:52 AM
To: joelle weaver; Amber McKenzie; Houston, Ronald; Histonet
Subject: RE: [Histonet] RE: competency form

What we had here, which did not meet the CAP inspectors requirements apparently, were the procedure (of course); a form with each observation of each task documented along with any corrective action necessary; the correlation of proficiency tests, educational assessments  and performance reviews for technical staff; daily evaluations from the pathologists concerning staining, microtomy and grossing; and educational training documentation. We had no idea with all pieces of this documentation that we were anticipated to have more. The form for DO of each task was not detailed enough (despite listing each task and proficiency or corrective action of each task) according to the inspectors. I was hoping someone could share a form so as to assist us in seeing what holes there are in our form. While this DO form is definitely not our only form, the inspectors specifically commented on this one.

If anyone can assist, it would be helpful.
Thank you,
Sheila Haas
MicroPath Laboratories, Inc.
Quality Assurance Coordinator

From: joelleweaver <@t> hotmail.com
To: smah2 <@t> msn.com; amber.mckenzie <@t> gastrodocs.net; ronald.houston <@t> nationwidechildrens.org; histonet <@t> lists.utsouthwestern.edu
Subject: RE: [Histonet] RE: competency form
Date: Wed, 9 Apr 2014 12:26:47 +0000

Is the question that Ronnie posed yesterday requesting justification of the need and extent of competency documentation for histology, or is it just a form needed? The general checklist pretty much sums up the necessity for doing, and required elements to me- GEN. 55500 and CLIA. Maybe I am not understanding?
As for a form, I would expect that the specific items on any forms will vary by your personnel and by the testing and processes you perform. 
What I did to document initial training and competency was a make a summary checklist for each "bench" with tasks and direct observations "DO" for initial training  & documentation of satisfactory performance before patient testing.
I just put all those checklists together in a summary table for each person. High complexity; such as grossing, IHC, FISH scoring get more attention and documentation, the waived tests, you have more discretion,- but I thought it easier to do everything about the same. I have not been inspected on this document yet ( so can't say if CAP will have issues with it- but will know soon...) but here is basically what I did to meet GEN.55500 or the main parts; 

Defined how competency is monitored- method and frequency ( just included as part of the competency SOP) Orientation and initial training documentation in a checklist for general lab, safety Training checklist on each technical bench, instrument, major procedure PT records and performance/results
DO- a practical assessment ( block, slides, stains),  for the assessment of previously analyzed specimens, and a PI feedback checklist for the technical from this audit of issues- how/what to improve Check off in performing QC, calibration, patient ID procedures ( acceptable error rates), examples for file DO of grossing, other performance such as instrument programming/maintenance Written quiz, policies & procedures, troubleshooting( problem solving documentation) Continuing education participation records

Joelle Weaver MAOM, HTL (ASCP) QIHC

> From: smah2 <@t> msn.com
> To: amber.mckenzie <@t> gastrodocs.net; 
> ronald.houston <@t> nationwidechildrens.org; 
> histonet <@t> lists.utsouthwestern.edu
> Date: Wed, 9 Apr 2014 11:10:18 +0000
> Subject: RE: [Histonet] RE: competency form
> CC: 
> 
> We were recently dinged by CAP for our competency assessments in all areas. While that's no longer my immediate responsibility, I would love to be able to assist the lab manager with some information so we can tweek our assessments if you all wouldn't mind sharing with me as well.
> Thanks a bunch.
> Sheila Haas
> MicroPath Laboratories, Inc.
> Quality Assurance Coordinator
>  
> > From: amber.mckenzie <@t> gastrodocs.net
> > To: Ronald.Houston <@t> nationwidechildrens.org; 
> > histonet <@t> lists.utsouthwestern.edu
> > Date: Tue, 8 Apr 2014 21:17:44 +0000
> > CC: 
> > Subject: [Histonet] RE: competency form
> > 
> > Can you pass it on to me as well?  I'd love to compare what I've got to what someone else is doing. 
> > Thanks,
> > Amber
> > 
> > -----Original Message-----
> > From: histonet-bounces <@t> lists.utsouthwestern.edu 
> > [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of 
> > Houston, Ronald
> > Sent: Tuesday, April 08, 2014 2:37 PM
> > To: Histonet
> > Subject: [Histonet] competency form
> > 
> > Can someone please share the competency form(s) they are using to satisfy CAP?
> > 
> > I am having problems convincing our QA/Compliance folks of the 
> > differences between testing in AP compared to the other lab 
> > disciplines, who do read our test results
> > 
> > Thanks
> > 
> > Ronnie Houston, MS HT(ASCP)QIHC
> > Anatomic Pathology Manager
> > ChildLab, a Division of Nationwide Children's Hospital 
> > www.childlab.com
> > 
> > 700 Children's Drive
> > Columbus, OH 43205
> > (P) 614-722-5450
> > (F) 614-722-2899
> > ronald.houston <@t> nationwidechildrens.org<mailto:ronald.houston <@t> nationw
> > idechildrens.org> 
> > www.NationwideChildrens.org<http://www.nationwidechildrens.org/>
> > 
> > "One person with passion is better than forty people merely interested."
> > ~ E.M. Forster
> > 
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