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INSPECTION READINESS KIT INSPECTION READINESS KIT

ABOUT THE INSPECTION READINESS KIT

This packet includes provisions from the Anatomic Pathology and Laboratory General Accreditation Checklists of the College of American Pathologists that have been licensed by the AAPA. This packet addresses only those Accreditation Checklist items directly related to pathologists’ assistants.

Frequently Asked Questions

Got questions? Read our FAQ.

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Frequently Asked Questions

The best advice we can provide?

The best advice we can provide is to be organized and always be inspection ready. You can also visit the CAP website for additional information on CAP inspections. Below are some tips and suggestions for CAP readiness in Anatomic Pathology.

Make sure to use the current version of the CAP checklist.

Make sure to use the current version of the CAP checklist. You may have received a custom checklist specifically designed for your laboratory if there are checklist items that do not pertain to your laboratory.

Read all the checklist requirements in their entirety, especially the notes section.

Read all the checklist requirements in their entirety, especially the notes section. Make certain to check the “Evidence of Compliance” section at the bottom of each checklist item to ensure you have a procedure for each task.

Evaluate your procedures, and make sure that they have been properly reviewed and signed within the past 2 years.

Evaluate your procedures, and make sure that they have been properly reviewed and signed within the past 2 years. Ensure that all policies and procedures and all logs are readily available to the inspectors. Check to make sure that there are no expired chemicals or reagents in the department (check your inks and mordants too). Have your fume exposure reports readily available first thing in the morning, as this is one of the first anatomic pathology checklist items reviewed by the inspector.

As far as the checklist items specifically dealing with specimen examination by a non-pathologist, make certain to have the following policies, procedures, or forms:

As far as the checklist items specifically dealing with specimen examination by a non-pathologist, make certain to have the following policies, procedures, or forms:

  • Histopathology quality assurance form that provides feedback to submitting pathologists and pathologists’ assistants on the quality of the gross tissue sections received for tissue processing.
  • Histologic preparation quality form for H&E and special stains.
  • Policy for macroscopic examination qualifications for personnel performing high complexity testing.
  • Competency assessments for pathologists’ assistants including:
    • Assessment addressing the six competencies
    • Supervisory level template for all types of specimens examined (direct supervision vs. indirect supervision)
    • Initial, six-month, and annual competency assessment records
  • Policy for autopsy performance and the pathologists’ assistant
Practice

Practice. Participate in mock inspection or tracer of the anatomic pathology laboratory.

© 2018 American Association of Pathologists’ Assistants. All rights reserved.

The purpose of the Inspection Readiness Kit is to assist pathologists, pathologists’ assistants and laboratory directors in achieving a successful CAP inspection. The American Association of Pathologists’ Assistants offers guidelines for personnel requirements and competency assessment for pathologists’ assistants.

This publication includes provisions from the Accreditation Checklists of the College of American Pathologists that have been licensed by AAPA. These Checklists are copyrighted works of the College and may not be copied without the express written consent of the College. AAPA wishes to thank the College for permission to use these provisions.

Disclaimer:
This document was prepared by the American Association of Pathologists’ Assistants (AAPA) for use by laboratory directors to provide guidance and assist them in creating protocols in accordance with the College of American Pathologists (CAP) Accreditation Checklists. It should not be relied upon as legal advice, representative of any specific business need or product, or to be used for any other purpose. The AAPA expressly disclaims any liability for any damage or loss that may arise from relying upon or using information contained in these documents. Use of these documents does not guarantee a successful CAP inspection or accreditation.

Lab General

Table of Contents

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  • Personnel Requirements for Pathologists’ Assistants
    • CAP Checklist items addressing personnel requirements applicable to pathologists’ assistants
    • What is a Pathologists’ Assistant?
    • Pathologists’ Assistant Onboarding
      • GEN.54000 Organizational Chart
      • GEN.54200 Continuing Education
      • GEN.54400 Personnel Records
      • GEN.54750 Testing Personnel Qualifications
      • GEN.55400 Visual Color Discrimination
      • GEN.55450 Initial Training
      • Sample New Employee Training Policy – Pathologists’ Assistant
  • Competency Assessment
    • GEN.55500 Competency Assessment of Testing Personnel
      • Sample Competency Assessment of Pathologists’ Assistants
    • GEN.57000 Competency Corrective Action
      • Sample – Competency Corrective Action Plan
  • Appendices (Forms and Templates)
    • APPENDIX A Sample Job Description – Certified Pathologists’ Assistant
    • APPENDIX B Sample Pathologists’ Assistant Delineation of Privileges
    • APPENDIX C Sample Pathologists’ Assistant Report Attestation
    • APPENDIX D Sample Pathologists’ Assistant Training Checklist
    • APPENDIX E Sample Medical Director Delegation of Competency Assessment Form
    • APPENDIX F Sample Initial Competency Assessment and Evaluation Form
    • APPENDIX G Sample Six Month Competency Assessment and Evaluation Form
    • APPENDIX H Sample Annual Competency Assessment and Evaluation Form
    • APPENDIX I Sample Surgical Pathology Specimen Evaluation List
      Frozen Section List
      Sample Pathologists’ Assistant Competency Assessment Summary
    • APPENDIX J Sample Competency Improvement Plan
  • Blank Sample Policy and Procedure Template

Anatomic Pathology

Table of Contents

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  • Specimen Examination by Pathologists’ Assistants
    • CAP Checklist items addressing specimen examination by pathologists’ assistants (non-pathologists) and autopsy performance
      • ANP.11038 Tissue Sample Quality
        Sample Histopathology Quality Assurance Report Form
      • ANP.11042 Histologic Prep Quality
        Sample Template for Routine H&E,
        Sample Template for Special Stains/Immunohistochemistry
        Sample Histologic Prep Quality/Tissue Sample Quality Policy
      • ANP.11605 Gross Examination – Non-Pathologist
        Sample Policy – Gross Examination – Non-Pathologists
        Editable Supervision Level Template/Delineation of Privileges
      • ANP.11610 Gross Examination Qualifications
        Sample Protocol for Gross Examination Qualifications for Personnel Performing High Complexity Testing
      • ANP.11640 Competency Assessment of Non-Pathologists
        Sample – Schedule for Assessing Competency of Non-Pathologists
      • ANP.33050 Autopsy Performance
        Sample – Policy for Autopsy Performance and the Pathologists’ Assistant
  • Appendices (Forms and Templates)
    • APPENDIX A Medical Director Delegation of Competency Assessment Form
    • APPENDIX B Initial Training Assessment and Evaluation Form
    • APPENDIX C Six Month Competency Assessment and Evaluation Form
    • APPENDIX D Annual Competency Assessment and Evaluation Form
      • Sample Pathologists’ Assistants Competency Assessment Program
      • Specimen Review Lists
      • Competency Assessment Summary
      • Competency Improvement Plan
      • Additional Sample Frozen Section Competency Template
    • CRITICAL THINKING QUESTION EXAMPLES Documentation of the Six Competency Elements for Frozen Sections
    • COMPETENCY CHECKLIST FOR AUTOPSY PERFORMANCE Documentation of the Six Competency Elements for Autopsy