Quality Improvement

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camt - 19 Apr 2004 07:25 GMT

Regarding the CAP questions on Quality Improvement. What are your
laboratories doing to address these questions?

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Manky Badger - 19 Apr 2004 19:44 GMT

> Regarding the CAP questions on Quality Improvement.

???

MB

>What are your
> laboratories doing to address these questions?

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JEDilworth - 20 Apr 2004 19:18 GMT

Can you be a bit more specific on the exact wording of the CAP regs? We
just had our two year inspection. Not being in management, I'm not
familiar with a lot of the verbiage CAP hands out.

Manky, CAP (College of American Pathologists) is a large accrediting
agency here in the US. CAP accreditation is voluntary but tends to lend
a feather to your cap.

http://tinyurl.com/2t65f

Judy Dilworth, M.T. (ASCP)
Microbiology

> ???
>>
> > Regarding the CAP questions on Quality Improvement.
> >What are your laboratories doing to address these questions?

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Manky Badger - 21 Apr 2004 00:16 GMT

> Can you be a bit more specific on the exact wording of the CAP regs? We
> just had our two year inspection. Not being in management, I'm not
[quoted text clipped - 8 lines]
> Judy Dilworth, M.T. (ASCP)
> Microbiology

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Kristine Quilici - 21 Apr 2004 02:27 GMT

Oh....

We have CPA (Clinical Pathology Accreditadion) which is (IMHO) a total farce
in that everyone works about four hours a day extra for six months to
acheive unsustainable levels of paperwork which are than abandoned once the
inspection is done. It's then business as usual for the next five years.

That is about what happens when a CAP insepction is due. The lab I work at
ususally starts about two months before the inspection.
Kristine Quilici

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Mike Collins - 21 Apr 2004 22:15 GMT

> We have CPA (Clinical Pathology Accreditadion) which is (IMHO) a
> total farce in that everyone works about four hours a day extra for
> six months to acheive unsustainable levels of paperwork which are
> than abandoned once the inspection is done. It's then business as
> usual for the next five years.

That was under the old system. With the new rules you have to have evidence
of regular audits between inspections. The farcical elemant of CPA is that
they take months to send out any of their paperwork. Just the confirmation
of receipt of the application for renewal of accreditation takes about 3
months.

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Mike Collins
UK
Mike&heather-at-oakwellmount-dot-freeserve-dot-co-dot-uk

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Manky Badger - 21 Apr 2004 23:03 GMT

> > We have CPA (Clinical Pathology Accreditadion) which is (IMHO) a
> > total farce in that everyone works about four hours a day extra for
[quoted text clipped - 4 lines]
> That was under the old system. With the new rules you have to have evidence
> of regular audits between inspections.

Audit, shmaudit ! - to quote my trainee.

What do they acheive but slow down the work !
In ant event they can be "created" like all the other CPA paperwork.

>The farcical elemant of CPA is that
> they take months to send out any of their paperwork. Just the confirmation
> of receipt of the application for renewal of accreditation takes about 3
> months.

Why bother with CPA ?
It's a whole load of unmaintainable nonsense !!!!

(Or am I being too harsh ?)

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kuhnfucius - 25 May 2004 04:12 GMT

collecting deficiencies, oh god its good to be helpful again...too much time
on my hands

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?There is another old saying senator....Don't piss down my back and tell me
its raining-The Outlaw Josey Wales
<stick.the.spam@wher.the.sun.don't.shine> wrote in message
news:c616kj$sh$1@newsg4.svr.pol.co.uk...

>
> > Regarding the CAP questions on Quality Improvement.
[quoted text clipped - 5 lines]
> >What are your
> > laboratories doing to address these questions?

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Lynn Gerber - 21 Apr 2004 05:15 GMT

> Regarding the CAP questions on Quality Improvement. What are your
> laboratories doing to address these questions?

We are currently accredited by COLA. They also require a significant amount
of Quality Improvement/Quality Assurence documentation.

It seems that one 'study' that is often used is turnaround time (TAT). I
usually pick 3-4 tests and a 2-week period. I then use an option from our
LIS that lists the TAT for those tests. You pick a threshold (45 minutes or
whatever) and document that x percentage of your tests fell within the
threshold. If you can show an 'improvement' from a previous study, that is
always a plus. We have also used other items to follow including error
reporting and critical value notification.

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