#06-5558 Accrd Manual V7 - COLA

CYTOLOGY>IntroductionThe following standards and criteria for cytology laboratories are unique to the discipline of cytology, and representadditional requirements for COLA accreditation.These criteria are divided into eight sections, each addressing a particular aspect of laboratory operation.Each section has:• Policy statements, which are preceded by a capital letter E (Essential) or R (Required),• Criteria interpreting those policies (numbered),• Notations (in italics) that explain the requirement in more detail.OrganizationThe cytology laboratory (or the organization with which it is associated) must be a legal entity, and must bein compliance with all applicable state and federal laboratory regulations.700. EIs the cytology laboratory, or the laboratory with which it is associated, a legal entity, and in compliance withlocal, regional, and national licensing requirements?The Laboratory may use any of the following items to establish it’s status: a federal tax identification number,state licensure and / or certification, and federal accreditation or certification / accreditation by a nationalorganization.701. EAre all cytology slide preparations examined on the premises of a laboratory certified to conduct testing in thesubspecialty of cytology?The laboratory must have a certificate of registration or a certificate of accreditation from the applicablenational and/or state authority.702. EDoes the cytology laboratory meet the general laboratory organization requirements for COLA accreditation?The cytology laboratory must meet the Laboratory Organization Requirements as outlined in questions700,701, 719, 723, 736, 737, 743, 775, 777, 798, and 805.PersonnelThe laboratory shall establish and implement a personnel management plan that includes personnel policies anda job description containing the qualifications, responsibilities and authorities for each position.Does the plan include policies to ensure that:703. EThere are job descriptions for each position in cytology including the director?704. EThe laboratory is directed by an individual with the appropriate professional education, experience and skillsnecessary for the services rendered and who meets all applicable local, regional, and national requirements.705. EThe supervisory personnel have the training and experience necessary for the services rendered and meets allapplicable local, regional, and national requirements.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org79