#06-5558 Accrd Manual V7 - COLA

CYTOLOGYAre there documented evaluations of the performance of all personnel that include:773. EA comparison of their performance with the overall laboratory statistical records?774. EA record of diagnostic discrepancies, reasons for the discrepancies and corrective actions taken?The laboratory shall have a Quality Assessment Plan which addresses all aspects of the operation of thecytology laboratory.775. EDoes the cytology laboratory meet the general quality assessment requirements for COLA accreditation?The laboratory shall be in compliance with all criteria within this subsection (755-774) & Quality Assessmentrequirements (QA 1 – QA 22).Proficiency TestingThe cytology laboratory shall participate in a proficiency testing program.776. EDoes the cytology laboratory participate in a proficiency testing program which provides challenges that coverthe extent of cytology practiced in the laboratory?777. EDoes the cytology laboratory meet the general proficiency testing requirements for COLA accreditation?The Laboratory should be in compliance with all criteria in this subsection, as well as general COLA criteriafor Proficiency Testing (PT 1 – PT 17).Specific CLIA Requirements for Proficiency Testing778. EDoes each individual engaged in the examination of gynecologic preparations participate in proficiency testingfor gynecologic cytology at least annually?779. EDo individuals who fail to achieve 90% retake the proficiency test within 45 days of notification of failure?780. EIf an individual fails the re-test, does the laboratory:• Provide him or her with documented, remedial training and education in the area of failure, and• Assure that all gynecologic slides evaluated subsequent to the notice of failure are reexamined until the individualis again retested with a 20-slide test set and scores at least 90 percent?781. EIf an individual fails a 20-slide test set (third consecutive failure), does the laboratory prohibit them from examininggynecologic slide preparations immediately upon notification of test failure?An individual who fails a 20 slide test set may not resume examining gynecologic slides for reporting purposesuntil the laboratory assures that the individual obtains at least 35 hours of documented, formallystructured, continuing education in diagnostic cytopathology that focuses on the examination of gynecologicpreparations, and until he or she is retested with a 20-slide test set and scores at least 90 percent.90. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org