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Interim Self-Inspection: What is it and How to do it - Session Materials

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2014 CONTINUING COMPLIANCE MASTER SERIES
Interim Self-Inspection: What is it and How to do it
March 19, 2014
John D. Olson, MD, PhD, FCAP
College of American Pathologists
325 Waukegan Rd.
Northfield, IL 60093
Tel: 800-323-4040
www.cap.org
Version no.1
OBJECTIVES
After participating in this Webinar you will be able to:
•
•
•
•
Explain the importance of the interim self-inspection
Apply best practices to your interim self-inspection
Describe how the interim self-inspection will help prepare you for an unannounced on-site
inspection
Describe how the interim self-inspection will help improve laboratory quality and promote
continuous compliance with accreditation requirements
CE (CONTINUING EDUCATION FOR NON-PHYSICIANS)
The CAP designates this educational activity for a maximum of 1.5 credit/hour of continuing
education. Each participant should only claim those credits/hours he/she actually spent in the
activity.
ASCP STATEMENT
The American Society for Clinical Pathology (ASCP) Board of Certification (BOC) Certification
Maintenance Program (CMP) accepts this activity to meet the continuing education
requirements.
CALIFORNIA AND FLORIDA STATEMENT
This activity is approved for continuing education credit in the states of California and Florida.
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
www.cap.org
Today’s Presenter - John D. Olson, MD, PhD
Dr. John Olson graduated from the University of
Colorado and received his Medical Degree from
Georgetown University. Following his residency at the
Mayo Clinic he received his PhD degree from the
University of Minnesota. He is currently Professor and
Vice Chair for Clinical Affairs in the Department of
Pathology at the University of Texas Health Science
Center in San Antonio and is the Director of the
Clinical Laboratories for the South Texas Reference
Laboratories.
Dr. Olson served on the CAP Coagulation Resource
Committee from 1993-2004, serving as its chair 19992004. He is currently a member for the Continuous
Compliance Committee. Dr. Olson’s academic
career has focused on issues of hemostasis and
thrombosis. He also has interest in quality
management in the laboratory.
В© 2014 College of American Pathologists. All rights reserved.
2
Learning Objectives
As a result of participating in this activity, you will be able to:
o Explain the importance of the interim self-inspection
o Apply best practices to your interim self-inspection
o Describe how the interim self-inspection will help prepare
you for an unannounced on-site inspection
o Describe how the interim self-inspection will help improve
laboratory quality and promote continuous compliance
with accreditation requirements.
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
3
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Purpose of the Self-Inspection
• Ongoing compliance with the Standards
• Update laboratory practice to comply with current
checklist requirements
• Prepare for the next on-site inspection
• Laboratory improvement and better patient care
В© 2014 College of American Pathologists. All rights reserved.
4
GEN.23584: Interim Self-Inspection
• The laboratory conducts an interim self-inspection
and documents efforts to correct deficiencies
identified during that process.
В© 2014 College of American Pathologists. All rights reserved.
5
GEN.23584 (Continued)
•
NOTE: The interim self-inspection is an important aspect of
continuing education and laboratory improvement. The use of a
variety of mechanisms for self-inspection (residents, technologists or
other inspectors) is strongly endorsed. Self inspection by personnel
familiar with, but not directly involved in, the routine operation of the
laboratory section to be inspected is a best practice.
Documentation of performance of the interim self-inspection with
correction of deficiencies is a requirement for maintaining
accreditation. The laboratory must document that personnel
responsible for each laboratory section have reviewed the findings
of the interim self-inspection.
•
Evidence of Compliance:
•
Written evidence of self-inspection findings with records of corrective
action
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
6
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Get a Fresh Look at Your Operations
Use the interim self-inspection to look at your
laboratory or have someone else look at your
laboratory as if seeing it for the first time.
В© 2014 College of American Pathologists. All rights reserved.
7
Let’s Get Organized
Plan for completion before your Self-inspection
Verification Form is due to be returned to the CAP:
1. Identify a Team Leader for your self-inspection
process (t-60 days)
2. The team leader will identify inspectors to perform
th self-inspection
the
lf i
ti
(t 4 d
(t-45
days))
3. Perform inspection (t-30 to t-15 days)
4. Team meets to review findings
5. Summation Conference (t-7 days)
6. Mail self-inspection confirmation to CAP (t-7 to t-1
days)
7. Corrective action and documentation (t+30 days)
В© 2014 College of American Pathologists. All rights reserved.
8
Team Leader
• Someone with experience with the inspection
process
• Has previously been a team leader or member of a
team inspecting another laboratory
• Has taken the Team Leader Training offered online
at CAP.org:
http://learning.cap.org/catalog/options/view/c
cf50d5a-9a33-438a-8872-469831d6194f
• An opportunity to lead a project
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
9
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Self-Inspection Team Members
• Use supervisory staff, experienced non-supervisory
technical staff, residents, fellows
• Cross discipline lines when practical
- Cultivates new team members for future inspections
- Provides depth for unannounced on-site inspections
- Prepares staff for inspection interviews
- Elucidates weaknesses
• Explore exchange with other laboratories in your region
• All team members should take the inspector training at
CAP.org:
http://learning.cap.org/catalog/options/view/d9c451f3
-addd-4d09-b24a-5b1f83d27a3e
В© 2014 College of American Pathologists. All rights reserved.
10
Initial Team Leader Meeting with Inspectors
1. Assignments and distribution of checklists
- Have the checklists provided for the inspection
- Be clear about the assignments for each team member
- Define any focus issues
2 Establish timing
2.
- Timing is flexible so set precise goals
- Lay out the entire timeline
3. Define communication and “esprit de corps”
- New members will have questions. Provide them support
- Collegial process, inspector and laboratory are both
learning
В© 2014 College of American Pathologists. All rights reserved.
11
Inspection Process
• Focus Issues
o Prior inspection deficiencies, on site or self-inspection
в€’ There is no reason for and there should not be
recurrence of prior deficiencies
o Known issues in your laboratory (products of your event
management program)
в€’ Many of the events that occur in the laboratory are
related to accreditation requirements
в€’ Check that all events have documented corrective
action; verify that you are compliant for accreditation
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
12
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
• Focus Issues
o Common problems (deficiencies) found in
inspections of other laboratories
- We will review some common issues that are
found during inspections generally.
- Data is a compilation of the findings of all CAP
inspections.
В© 2014 College of American Pathologists. All rights reserved.
13
Inspection Process
• 2012: Common Deficiencies
o Among the checklist items, many laboratories
are cited for the same issues
o Comparing the current list of common
deficiencies to those of prior years, we find
that the most frequently cited deficiencies
are similar from one year to the next, and do
not necessarily involve new requirements
В© 2014 College of American Pathologists. All rights reserved.
14
Inspection Process
Most Common Deficiencies in 2012
GEN.55500 Competency Assessment
GEN.20375 Document Control System
GEN.75400 Annual Fire Drill
COM.01700 Proficiency
y Testing
g (PT)
( ) Evaluation
COM.10000 Complete Procedure Manual
COM.01400 PT Attestation Statement
CHM.10100 Procedure Review
POC.06900 Competency Assessment
CHM.13600 AMR Validation
COM.10300 Knowledge of Procedures
0
100
200
300
400
500
600
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
15
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
Five Phase II Items Most Often Cited from the All Common
Checklist:
o COM.01100 Laboratory has procedure for grading
challenges intended to be graded, but which were
not
o COM.01500 Alternative Assessment
o COM.01600 Proficiency Testing Integration into
Routine Workload
o COM.01700 Proficiency Testing & alternative
assessment: evaluation and corrective action
o COM.10100 Procedure Manual Review had been
annual, now at least every two years
В© 2014 College of American Pathologists. All rights reserved.
16
Polling Question 1
While performing your self inspection, you are asked to
review the Proficiency Testing records. You find that your
Director has correctly signed every attestation sheet for the
past 2 years except for the A mailing of the CGL survey this
year.
Whatt do
Wh
d you do?
d ?
A. Cite a Phase II deficiency for failure to sign the
attestation.
B. Issue a recommendation the laboratory has
established practice of signing.
C. This is minor, cite yourself for only a Phase I
deficiency.
В© 2014 College of American Pathologists. All rights reserved.
17
Inspection Process
Most Cited Discipline Specific Deficiencies in 2012
POC.06900 Competency Assessment
CHM.13600 Validation of Analytic Measurement Range
TLC.11425 Delegation of Director Duties
CHM.13800 Method Comparisons
MIC.11020 Quality Control Monthly Review
POC.07300 Daily Control Testing
TRM.31450 Method Comparisons
HEM.24000 Reagent Labeling
ANP.12087 Cryostat Decontamination
ANP.08216 Formaldehyde Monitoring
0
100
200
300
400
500
600
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
18
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
CHM.13600 (Phase II) Validation of the analytical
measurement range (AMR) is performed with matrixappropriate materials which include the low, mid and
high range of the AMR, appropriate acceptance criteria
are defined, and the process is documented.
Common reasons for citations:
o Did not revalidate every 6 months
o Did not include materials than span the assay range
o Did not include all applicable analytes in the
validation process (e.g. blood gases, BNP, and TNI)
o New issue in Hemostasis that is generating questions
В© 2014 College of American Pathologists. All rights reserved.
19
Inspection Process
TLC.11425 (Phase II) If the laboratory director has
delegated some functions to others, documentation
specifies the individuals and the specific activities so
authorized.
Common reasons for citations:
o No documentation
o Duties or individuals not included
o Delegated activities that must not be delegated
such as new procedure or policy review
o Letter/memo needs to be specific regarding the
duties that are being delegated
В© 2014 College of American Pathologists. All rights reserved.
20
Inspection Process
CHM.13800 (Phase II) If the laboratory uses more
than one instrument/method to test for a given
analyte, the instruments/methods are checked
against each other at least twice a year for
correlation of results.
Common reasons for citations:
o Not performed twice per year
o Not including all the appropriate
instruments/methods
o No established criteria for acceptability
o Also TRM.31450 (Phase II)
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
21
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
MIC.11020 (Phase II) Quality control data are
reviewed and assessed at least monthly by the
laboratory director or designee.
Co
Common
o reasons
easo s for
o c
citation:
a o :
o No documentation
o Not completed monthly
o Not performed by a documented designee
o Also POC.07300 Managing controls for POCT
В© 2014 College of American Pathologists. All rights reserved.
22
Inspection Process
ANP.23410 (Phase II) There is a documented
procedure for the routine decontamination of the
cryostat at defined intervals, and decontamination
records are evident.
Common reasons for citations:
o Lack of documentation
o Laboratories sometimes use uv or fog, but do not physically
wipe the cryostat down
o Laboratories aren’t using the cryostat daily and are unsure
of the frequency of decontamination
o Laboratories have a difficult time decontaminating once
per week due to high volumes and only one cryostat
available.
В© 2014 College of American Pathologists. All rights reserved.
23
Inspection Process
ANP.08216 (Phase II) Formaldehyde and xylene
vapor concentrations are maintained below the
following maxima, expressed as parts per million, in
all areas of the Anatomic Pathology Department
where formaldehyde or xylene are used.
Common Reasons for Citations:
• Laboratories sometimes don’t do both the 15 minute and the 8
hour monitoring
• Laboratories have small quantities of these chemicals and
believe that the requirement does not apply to them.
• Do not repeat the monitor when changes have taken place in
the laboratory that could potentially increase exposure such as
changes in production, equipment, personnel
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
24
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Polling Question 2
While performing your self inspection you find a procedure was
last reviewed and signed 18 months previously. Your laboratory’s
quality plan states that procedures are reviewed annually.
What do you do?
A. Current CAP regulations require review every 24 months so
this is compliant.
compliant
B. The laboratory’s policy states the review is to be every 12
months. This is a Phase II deficiency.
C. The laboratory’s policy states the review is to be every 12
months. Write a recommendation to update the policy.
В© 2014 College of American Pathologists. All rights reserved.
25
Inspection Process
Encourage inspectors to:
o Spend time in the laboratory!
o Interview non-supervisory staff (bench techs,
phlebotomists, order entry personnel)
в€’ Structure
St
t
the
th interim
i t i self-inspection
lf i
ti
tto b
be
as similar to the on-site inspection as
possible:
в€’ Interview non-supervisory personnel during
the self inspection -- does everyone know
the policies as well as the supervisors?
В© 2014 College of American Pathologists. All rights reserved.
26
Inspection Process
Testing Readiness
o “If your supervisor were not here on the day of
the inspection, how would you respond if you
were asked by the inspector…”
− …for a certain procedure or practice?
− …where PT policies are located?
− …where the Chemical Hygiene plan is housed?
− …where the maintenance records are kept?
− …etc.
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
27
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
• An Example:
What’s the problem?
• GEN.41067 (Phase II)
• No written policy.
• “Does the Laboratory
director review the
format of the report on
a bi-annual basis?”
• No documentation
that this is occurring.
occurring
• I look at report formats
every day!
В© 2014 College of American Pathologists. All rights reserved.
28
Inspection Process
The Lesson:
• Provide
documentation that
the activity is being
performed.
• “If you didn’t
write it down, it
didn’t
h
happen……”
”
• Failure to document
equals noncompliance.
В© 2014 College of American Pathologists. All rights reserved.
29
Inspection Process
Famous Last Words
“Oh yes, we do all of that all of the time!”
Dr. I. M. Complacent,
Medical Director
Mediocre Laboratories,
Laboratories USA
When you are in a familiar environment, same place and activity,
day after day, you can overlook details, forget best practices
and become complacent.
Consistency is also an issue. Do all of the staff perform the same
procedures the same way.
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
30
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
Safety
o Safety procedures and policies posted readily
available to all employees?
o Documentation of safety training to new
employees
employees.
o During the Interim Self-Inspection, interview
personnel regarding contents of the safety
manual.
в€’ Choose several items to ask non-supervisory
staff.
В© 2014 College of American Pathologists. All rights reserved.
31
Inspection Process
Competency Assessment
o During the first year of patient testing,
competency assessment must be performed
every six months.
o Competency must be reassessed at least
annually
annually.
o Confirm all six elements are included for each
test system (if applicable).
o Managing Competency for POCT is a problem
in many institutions.
o PPMP now requires competency with the same
detail as others who perform testing.
В© 2014 College of American Pathologists. All rights reserved.
32
Inspection Process
Point of Care Testing
o Inspection of POCT requires the use of the POCT
checklist and all applicable portions of the
Laboratory General checklist.
o For accreditation
accreditation, all analytes being measured
under the program/site are included in the live
CAP inspection.
o POCT is often overlooked in the self-inspection.
o Not in the Laboratory, but the Laboratory
provides oversight. Be sure all elements are
compliant.
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
33
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
(GEN.20375) Elements of Document Control System
• Policies, procedures and processes (P/P/P) current
• Personnel have read the relevant documents
• P/P/P have been authorized by the director
• P/P/P reviewed annually by the director or designee
• Discontinued P/P/P are archived and quarantined a in
separate file
• Are all required elements present? Are Documents
current?
В© 2014 College of American Pathologists. All rights reserved.
34
Polling Question 3
Your laboratory has a new director. She started as the
director just a month ago. As you review the procedures,
you note that only one new major revision has occurred
that she has signed. All other procedures have been
signed by the prior director.
What do you do?
A The
A.
Th new director
di
t mustt only
l sign
i
the
th new procedures
d
from
f
her start date, not prior procedures.
B. Cite a Phase II deficiency. The new director is required to
approve and sign ALL procedures.
C. The director must sign all procedures but is allowed a
“reasonable time” to complete the task.
В© 2014 College of American Pathologists. All rights reserved.
35
Inspection Process
Team Leader Assessment of the Laboratory Director
and Quality Checklist
• Evaluate the qualifications of the Laboratory
Director.
• Assess the effectiveness with which that individual
implements and supports the Standards of the
Laboratory Accreditation Program.
• Conduct the interview, it can help provide depth
for the on-site inspection.
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
36
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
Team Leader Assessment of the Laboratory Director and
Quality Checklist
• Review documents:
o QM plan -- include review of specific monitors,
corrective actions.
o Organizational
O
i ti
l chart
h t -- does
d
it representt operations?
ti
?
• Has there been a change in the Laboratory Director?
o COM.10400: If there is a change in laboratory
directorship, the new laboratory director reviews and
approves (over a reasonable period of time) that
laboratory procedures are current.
в€’ Create your own goals, write them down and
document that you are progressing.
В© 2014 College of American Pathologists. All rights reserved.
37
Inspection Process
Quality Management
• Your event management program drives much of
your quality management
• Thoughtful selection of indicators
• Corrective actions documented
• Director’s involvement in development and
management of Quality
В© 2014 College of American Pathologists. All rights reserved.
38
Inspection Process
Review of Proficiency Testing
• Variant Proficiency Testing performance report
• “Drill down” troublesome analytes
• Alternative Assessment
• Do not share or refer Proficiency Testing results!
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
39
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspection Process
Patient Safety Policy
• Rigorous adherence to patient identification
procedures
• Reporting of life threatening conditions/ critical
values
• Strategies for preventing medical errors
• Institutional approach
В© 2014 College of American Pathologists. All rights reserved.
40
Inspection Process
Handling of Complaints
• Honestly review the culture of your laboratory.
• Do a policy and procedure exist?
• Do the policy and procedure match actual
practice?
В© 2014 College of American Pathologists. All rights reserved.
41
Team Meeting at Completion of Inspection
• Review all deficiencies identified during the
inspection
o Common issues may arise
o Discuss any issues about which an inspector may
be uncertain
• Organize the summation conference
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
42
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Summation Conference
• Hold a formal summation conference
• Invite the leadership of the organization
o Hospital Administration, Director of Organization,
Quality
o Your opportunity to shine
• Identify the strengths and quality of the laboratory
• Review the opportunities for improvement that have
been identified
o All inspectors or just the team leader
• Open and Close on a positive note
В© 2014 College of American Pathologists. All rights reserved.
43
Paperwork
• Send to the CAP:
o Self-inspection Verification Form
в€’ Signed by Director
В© 2014 College of American Pathologists. All rights reserved.
44
Corrective Actions
• Plan corrective action for all cited deficiencies
• Collect documentation that the corrective action
has addressed the problem
• Complete these tasks within ? days,
days fix the time
frame
• File the information for review by the next on-site
inspection team
• In 6 months, pull the file and document that the
corrective actions have been successful
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
45
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Inspector Summation Report: Five Crucial Questions
At your on-site inspection, the inspection team leader
with write a report including the following elements.
Consider these same elements as you conclude the
self-inspection process:
1. Does the laboratory
y meet the standards?
2. Is the Director qualified?
3. If no, is there a qualified supervisor for each
section?
4. Is administration satisfied?
5. Is the medical staff satisfied?
В© 2014 College of American Pathologists. All rights reserved.
46
What Inspectors Will Focus on About Your SelfInspection
• Inspectors have been instructed to review the
results of the interim self-inspection
o Request list of cited deficiencies and scrutinize
documentation of corrective action
• Probing questions will be asked about the selfinspection
o How seriously did the laboratory take the
process?
o Were genuine concerns detected and
corrected?
В© 2014 College of American Pathologists. All rights reserved.
47
Summary of Best Practices
• Involve multiple staff members in the self-inspection
• Make this a formal event for your laboratory
• Look at your laboratory as if you are seeing it for the
first time
• Ask questions of the bench technologists and other
staff
• Hold a summation conference encouraging all who
are able to attend
• Document corrective action for all deficiencies
cited
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
48
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
The Interim Self-Inspection – The Bottom Line
The laboratory is required to perform the interim selfinspection, but don’t do the inspection because it is
required, do it because it will help you maintain and
improve the quality of your laboratory. Sustaining
continuous compliance
p
with the accreditation
standards is a challenge for Laboratories regardless of
size and complexity and requires a robust quality
program. The inspection process is an important
integral part of that program and, when performed
well, helps the continuous improvement of the
Laboratory.
В© 2014 College of American Pathologists. All rights reserved.
49
Acknowledgements/Thank You
• Thanks to Dr. Renee Ellerbroek and Dr. Earle Collum
• Thanks to Continuous Compliance Committee
members, Accreditation Education Committee
members, Suzan Mraibie, Jean Ball, Rodney Stewart
and
d other
th CAP staff
t ff for
f assistance
it
in
i preparing
i
this
thi
presentation.
• Thank you to our participants for their time.
Keep in mind the tool kit is available with the link
your site coordinator has received
В© 2014 College of American Pathologists. All rights reserved.
50
Questions
В© 2014 College of American Pathologists. All rights reserved.
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
51
2014 Continuing Compliance Master Series
Interim Self-Inspection: What is it and How to do it
John D. Olson, MD, PhD, FCAP
March 19, 2014
Technical Assistance
http://www.cap.org
Email: accred@cap.org
800-323-4040, ext. 6065
В© 2014 College of American Pathologists. All rights reserved.
52
53
В© 2014 College of American Pathologists. Materials are
used with the permission of the faculty.
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