CAP Proficiency Testing Manual - Home - College of ... Folders...College of American4 Pathologists Proficiency Testing Manual CAP Identification Number Each participant receives a CAP identification number that is

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  • cap.org

    ProficiencyTesting Manual

  • Table of ContentTable of ContentssSurveys & Educational Anatomic Pathology Programs Manual

    1 Order Confirmation, Specimen Handling, and Customer Service 37

    n Confirmation 3 n RegulatoryReporting 3 n Binders/Glossaries 3 n AlertingtheMailroom 3 n CAPIdentificationNumber 4 n ReplacementSpecimens 4 n TestingInstructionsandCompletionTime 4 n ChangingResultsandCMSReportingInstructions 4 n Fax-BackResponsePrograms 5 n EvaluationReports 5 n Corrections 5 n CustomerSupport 5 n ProgramCertificates 6 n Letters 6 n LimitationsofProficiencyTesting 6 n HandleWithCaution 6 n LaboratoryAccidents 6 n LimitationsofProficiencyTestingLetter 7

    2 General Comments 89

    n CompletingtheResultForm 8 n Teleforms 8 n PreprintedMethodSummaryPage 8 n ExceptionCodes 8 n IdentificationMasterLists 9 n Method/InstrumentMasterLists 9 n Handwriting 9 n DecimalPointsandBoxPositions 9 n LessThanorGreaterThanValues 9

    3 e-LAB SolutionsTM 1011

    n UsingOnlineFeatures 10 n Security 10 n OnlineDataSubmission 11 n InteractiveEvaluations 11 n OnlineReports 11 4 How to Interpret the Evaluation Report 1214

    n GeneralGuidelinesforEvaluation 12 n SelectionofaTargetValue 12 n CalculationofSummaryStatistics 12 n ComparativeStatistics 14

  • Interlaboratory Comparison Program Cycle

    5 Continuing Education 1517

    n CMECategory1 15 n CEforCytotechnologists 15 n ContinuingEducation(CE)forNonphysicianLaboratoryPersonnel 16 n EXCELCEProgram 16

    6 Discipline-Specific Reporting Information 1819

    n HowtoCompletetheResultForm 18

    7 The Evaluation and Participant Summary Reports 2022

    n YourEvaluationReport 20 n ReviewingYourEvaluationReport 20 n TheParticipantSummary 21 n HowtoPerformaSelf-Evaluation 21

    8 Laboratory Legislation and Centers for Medicare and Medicaid Services (CMS) Reporting 2328

    n ProvisionofResultstoCMSandStateAgencies 25 n UseofReasonCodesforNonevaluatedSpecimens 26 n CMSPerformanceSummaryData 27

    Surveys & Educational Anatomic Pathology Programs Manual

    1CAP 2 Subscriptions SeptemberDecember:Yourlaboratoryplacesitsorder.Your Laboratory 3CAP Order Processing SeptemberDecember: Orderquantitiesarereserved. Catalog Delivery September:Thecatalogissenttoyour laboratory.

    4CAP 5 Kits Mailed Kitsareprepared andsentfromthe manufacturertoyour laboratory.

    Surveys Mailing 6Your Laboratory Result Form Completedresultforms arereturnedviamail,fax,or onlinesubmissiontotheCAPwheredataaresummarized.

    Order Confirmation SeptemberDecember: Confirmationreportsaresenttoyourlaboratoryafteryourorderisprocessed.

    7Scientific Resource Committee 8 Reports Mailed/ Available Online Reportsaresenttoormadeavailableonlineforyour laboratory,regulatory agency,and/orconsultants.

    CAP 9Certificate Certificate of Participation AsaCAPSurveysand AnatomicPathology EducationalProgramsand EXCELsubscriber,your laboratoryisentitledtoreceive aCertificateofParticipation.Thecertificatewillbeissuedatthe beginningoftheprogramyear.

    Evaluation Criteria Thescientificresource committeereviewsresultsandtheimpactofevaluationcriteria.

  • 1OrderConfirmation, SpecimenHandling, andCustomerService

    ConfirmationAfteryourorderisreceived,anorder confirmationreportissentthatcontainsthe followinginformation:

    n Shippingaddress

    n Billingaddress

    n Telephoneandfaxnumber

    n Listofproductsordered

    n Listofagenciesand/orconsultantsto whomyouhaverequestedcopiesof yourevaluationreportbesent

    Pleasereviewyourlaboratoryorderconfirmationreportcarefully.Ifyouhavechanges,returntheformwithintwoweeksofreceiptto:

    CustomerDataManagement CollegeofAmericanPathologists 325WaukeganRoad Northfield,Illinois60093-2750 847-832-8168(fax)

    Regulatory ReportingTheCAPwillautomaticallyforwardresultsforanalytesregulatedforproficiencytestingtotheCentersforMedicareandMedicaidServices(CMS)forlaboratoriesthathaveprovidedaCLIAidentificationnumber.

    Torequestthatnoresultsbeforwardedortomakechangestoyourlaboratorysanalyte selectionreportfortheinformationprovidedtoCMS,pleasecontacttheCustomerContact

    Centerat800-323-4040option1oraccessyourreportonlineatcap.org.

    Documentationwillberequestedandmaybefaxedto847-832-8168.Anexplanationof regulatoryreportingandcurrentlaboratory legislationisincludedinChapter8ofthismanual.

    Binders/GlossariesPleaseseeyourcatalogforinstructionsonhowtoobtainthree-ringbindersforfilingresultsandreports.Surveysresultsareprintedonthree- hole-punchedsheetsforstorageinthebinders.

    Ifyouareenrolledinhematologyand/orclinical microscopySurveyscontainingphotographsfor morphologicidentification,youwillbeabletoaccessanonlineglossaryoftermsforyour generaluse.Ifyouneedahardboundcopy,pleasecalltheCAPCustomerContactCenter.

    Alerting the MailroomRefertotheshippingscheduleandadviseyour receivingdepartmentaccordingly.Ashippingscheduleisprovidedtoyourlaboratorywith theorderingcatalog,oryoucanobtaina customizedshippingcalendarthroughe-LAB Solutionsatcap.org.

    Thereceivingdepartmentofyourhospitalorlaboratoryshouldbeadvisedhowtohandle theCAPkits.Insistonprompttransfertothe laboratory.(Kitsreceivedbythehospitalbut notdeliveredtothelaboratoryarenot eligibleforfreereplacement.)Unlessotherwisespecified,storethespecimensintherefrigerator.

  • CollegeofAmericanPathologists ProficiencyTestingManual 4

    CAP Identification NumberEachparticipantreceivesaCAPidentificationnumberthatisprintedonallresultforms.Thisnumberwillalsoappearoneachevaluationreportreceivedbyyourlaboratory.ItishelpfultohavethisnumberavailablewhencontactingtheCollege.

    Replacement Specimens Thekitscontainaresultformandspecimensfor analysis.Checkthecontentsofthekitagainsttheinstructions.EXCELparticipantsshouldverifythatallmoduleslistedonthemailingpageareincludedinthekit.Ifthekitisincompleteor containsbrokenorunlabeledspecimens, contacttheCollegewithinthenumberofdaysindicatedinthekitinstructionsfollowingtheactualshippingdateforafreereplacement.Additionalreplacementspecimensmaybepurchasedwithinthesametimeframe.Becauseproficiencytestingmaterialsmustbeprocuredinadvanceofshipment,onoccasion, additionalinventoryisavailableforanominalfee.TopurchasethesematerialscontacttheCustomerContactCenterat800-323-4040 option1.Allliteratureassociatedwiththis productincludingthesummarydatawouldbeprovided.This option does not replace routine proficiency testing.

    Thesematerialsmaybeusedforbutnotlimitedto:

    nCompetencyassessment

    nInstrumenttroubleshooting

    nTraining

    nEducation

    nResearch

    Intheeventthatareplacementspecimenisrequired,retainyouroriginalresultformwhileawaitingthearrivalofthereplacement specimens.Thereplacementspecimenswill besentinthesamemannerasyouroriginal specimens.Whenyoureceivethe replacementspecimens,youwillbeallowed thesameamountoftimeforanalysisaswas allowedwiththeoriginalshipment.Youare ensuredanevaluation.

    Occasionally,itmaynotbepossibleforthe manufacturertoreplaceyourspecimen(s)kit. Inthiscase,filltheexceptioncode33bubble ontheresultform.SpecimenProblemwill appearonyourevaluationreport,andyou willnotbepenalized.

    Testing Instructions and Completion TimePertheFederal Register,proficiencytesting(PT)specimensmustbetestedwiththelaboratorysregularworkload,usingroutinemethodsandtestingthePTspecimensthesamenumberoftimesitroutinelytestspatientspecimens.

    WhenhandlingPTspecimens,laboratoriesmustnotcommunicateresultsnorshareorrefer specimensfortestsnotonthelaboratorysmenu.Ifreferralfortestingisroutinelyperformedforpatientspecimens,thepracticecannotbefollowedforPTspecimens.Referralisconsideredtobemovementofthespecimenfroma laboratorywithaCLIAidentificationnumbertoanotherlaboratorythathasadifferentCLIAidentificationnumber.LaboratoriesmustensurethatpersonneldonotshareresultsorreferPTspecimensforanyreflexortestingoutsidetheirCLIAidentificationnumber.

    TheSurveysandEXCELprogramsareusedforcertificationofcertainlaboratories.Sincepromptnessisconsideredindeterminingcertification,wecannotacceptlateentries.Results are due by the date noted on the result form. Resultformsreceivedbeyondthedatenotedwillnotbeevaluated.Participantswill receiveanevaluationindicatingthattheresultswerereceivedpasttheevaluationcut-offdatealongwithaParticipantSummarythatcanbeusedforself-evaluation.

    Changing Results and CMS Reporting Instructions n Changestosubmitteddatacannotbe madeaftertheduedatelistedonthe resultform.Reviewallentriesmadeon theresultformforaccuracypriorto submission.Forresultsapprovedonline, correctionsmustalsobedoneonline. Faxedormailedcorrectionswillnotbe accepted.

    n Ifyouhaveregisteredyourlabonthe CAPwebsite,youmayuseResultForm Verificationtoverifysubmittedresults.

    n Foranytestingthatyoudonotroutinely performinyourlaboratory,leaveall reportingareasforthattestblank, includingmethodinformation.Please note, a penalty will not be applied for blank responses in the case of

    OrderConfirmation,SpecimenHandling,andCustomerService

  • 800-323-4040|847-832-7000Option1|cap.org 5

    educational challenges, challenges not formally graded, or the proper use of exception codes. n Ifyoudonotperformspecifictestingina Surveysprogram,pleaserefertothekit instructionsandresultformforthe appropriateinstructions.

    Foranyregulatedanalytesthatyourlaboratorydoesnotreportormayhavediscontinued,youmustnotifytheCAPinwriting.PleasefaxanychangesinwritingonyourCMSreportto 847-832-8168toavoidreceivingazeroscore onyournextPTevaluation.(Yourreporting preferencesareoutlinedontheCMSAnalytesReportingSelectionsdocument,whichis availableonlineatcap.orgontheAccreditationandLaboratoryImprovementtab.)Ifyouhaveanyquestions,pleasecalltheCustomerContactCenterat800-323-