[Histonet] Re: High complexity testing

Terri Braud tbraud <@t> holyredeemer.com
Wed Apr 9 12:12:58 CDT 2014


Just to clarify, IHC is not high complexity testing.

Terri L. Braud, HT(ASCP)
Anatomic Pathology Supervisor
Holy Redeemer Hospital Laboratory
1648 Huntingdon Pike
Meadowbrook, PA 19046
Ph: 215-938-3676
Fax: 215-938-3874


Message: 12
Date: Wed, 9 Apr 2014 12:26:47 +0000
From: joelle weaver <joelleweaver <@t> hotmail.com>
Subject: RE: [Histonet] RE: competency form

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
 
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