Jan made a good point that I forgot to mention. If a procedure was added or
greatly edited, I used those procedures to do an in-service. Everyone signed
the in-service and I killed two birds with one stone: had an in-service and
everyone signed the new or revised procedure.
----- Original Message -----
From: "Janice Mahoney"
To: ; "Joe Nocito" ;
Sent: Friday, August 03, 2007 10:35 AM
Subject: Re: [Histonet] Techs Documenting Knowing Procedure Manual
>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" 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"
> 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
>> 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
>> 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
>> 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
>> 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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