36C24219R0183-040.pdf

D.13 ANCILLARY SITE PROFICIENCY TESTING

I. PRINCIPLE: Each ancillary testing site is enrolled in the laboratory's College of American Pathologists

(CAP) proficiency testing program as appropriate for the scope of testing at each site. CAP Surveys are shipped two or three times per year.

There must be no interlaboratory communication. Sending proficiency samples to another facility for testing, or communication about test results (including photocopies or online access) prior to the submission deadline date is strictly prohibited.

II. SCOPE/RELATED POLICIES:

• Proficiency and Competency Assessment

• Proficiency Testing

• Ancillary Testing Policy (113-05)

III. RECORDS AND FORMS:

• Proficiency Testing History Form

IV. PROCEDURE:

A. Testing

1. Mark date received on page one of the result form and initial.

2. Read all instructions and provide any information requested, i.e. method code. If you have any questions regarding the instructions, call the ancillary testing coordinator in the clinical laboratory at x65771 or the nursing manager of the CBOC. Obtain replacement material (if needed) by calling the number provided in the instruction book.

3. The Ancillary Testing Coordinator (ATC) may travel to the testing site to observe testing personnel perform the test(s) and complete result forms as part of the ongoing competency assessment if needed.

4. Perform the test on the survey material exactly as if it were a routine patient sample. This includes documentation on the patient test log. Testing personnel (nurse or tech) should participate in at least one mailing per year per test.

5. Using blue or black ink, carefully fill out the original test result form. Make sure each number is clear by avoiding loops, “German 7”, or marked-over corrections. Use white out to make corrections if needed. Do not use pencil and honor the decimal point provided.

6. Sign the attestation statement on the last page.

7. Perform a secondary clerical error review prior to submitting results.

8. If the ATC or designee is not available, the site manager is designated to perform the clerical error review and sign the attestation statement.

9. Return the test result form within 10 working days or the submission deadline date printed on the result form. Results must be received by the submission date or else it is considered a failure.

10. Submit results online (preferred method). If results cannot be posted online, Fax all pages of the result forms to the number indicated at the upper left of the 1st page:

1-866-“FAX-2CAP” (1-866-329-2227).

Use a Fax cover sheet and save the confirmation page with the result forms.

Note: Fax results do not supercede results previously submitted online.

11. If the Fax machine is out of order or the transmission is not confirmed, make a photocopy of the test result forms for your records and mail to:

College of American Pathologists P.O. Box 800 Northfield, Illinois 60093-0800

12. File your copy (or photocopy)

13. Keep the survey material in the refrigerator until the evaluation report has been returned and reviewed. The material may be needed for corrective action if performance was not acceptable on the report.

B. Evaluation Report

• Mark the date received in the upper right corner underneath the date mailed.

• Review the results for performance acceptability and initial.

• File report.

• The Stratton VAMC clinical laboratory should receive a consultant copy. The ATC, Chief Medical

Technologist, and Consultant Pathologist review it for satisfactory performance.

• Under the guidance of the ATC, corrective action will be performed if needed.

• The ATC (or designee) will sign the site’s evaluation report

C. Ancillary Testing Site Cap Survey Subscriptions:

• Bainbridge

• Catskill

• Clifton Park

• Elizabethtown

• Fonda

• Saranac Lake

V. REFERENCE

• CAP General Check List