SOPs for the Yorkshire General Histopathology EQA Scheme

STANDARD OPERATING PROCEDURES
Standard Operating Procedure 24: Persistent
Substandard Performance
(CPA Standards: E2, E4, E5, F4)
Persistent substandard performance is identified when a participant scores below
the 2.5 percentile mark twice within three circulations. Following the identification
of those falling below the 2.5 percentile mark the Scheme Secretary checks if any
of these individuals have scored below this mark in either of the two preceding
circulations.
If a persistent substandard performer is identified, the Scheme Organiser sends a
“Dear Colleague” letter to the participant, through the Scheme Secretary to
maintain anonymity. This includes a copy of their results for the circulations
where they scored below the 2.5 percentile mark. The intention of the letter is to
offer appropriate advice and assistance and to inform the participant that if the
score results in a similar ranking in two out of the next three circulations, the
Chairman of the NQAAP will have to be asked to investigate. It should also be
made clear that for the next three circulations, a failure to participate will be
considered to be a score of zero. This letter should be sent within one month
following the distribution of the final results.
The participant is asked to confirm that this letter has been received, by reply
through the Scheme Secretary, bearing no identifying marks other than the
participant’s code number. If this is not received within three weeks, the Scheme
Organiser sends a reminder; if a reply is not received within another three weeks
they are then required to inform the NQAAP Chairman of the position. This letter
is identified by the participant’s number managed through the Scheme Secretary.
Filename: yorkshire histo
eqa sops v8
Version No: 8.0
Date Created:
01/08/2013
Last Revised On:
01/08/2013
Review Date: 08/14 Page 28 of 47 Author: Leeds
Office MW
Authorised By: