the cap inspection and accreditation program at age 50 - American ...
the cap inspection and accreditation program at age 50 - American ...
the cap inspection and accreditation program at age 50 - American ...
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Man<strong>age</strong>ment Requirements4.7 Make sure <strong>the</strong>re iscommunic<strong>at</strong>ion betweenlab director <strong>and</strong> clinicians.Man<strong>age</strong>ment Requirements4.8 Take complaints seriously. Contain problems, analyze<strong>the</strong>ir causes, <strong>and</strong> prevent future problems.4.9 Insure th<strong>at</strong> lab has resources <strong>and</strong> plans to resolve qualityissues, even those th<strong>at</strong> haven’t yet affected p<strong>at</strong>ients.4.10 Take corrective action based on root cause. Focus onproblem causes, not <strong>the</strong> person.©2008 College of <strong>American</strong> P<strong>at</strong>hologists. All rights reserved.Every number is a life.©2008 College of <strong>American</strong> P<strong>at</strong>hologists. All rights reserved.Every number is a life.Man<strong>age</strong>ment RequirementsMan<strong>age</strong>ment Requirements4.11 Analyze d<strong>at</strong>a <strong>and</strong> look for things th<strong>at</strong> could gowrong. Prevent mistakes.4.12 Challenge existing metrics <strong>and</strong> goals. Continuallylook for better ways to do <strong>the</strong> work.4.13 Make sure your records are man<strong>age</strong>d so you canquickly access d<strong>at</strong>a to reconstruct wh<strong>at</strong> hashappened in <strong>the</strong> past.4.14 Self-evalu<strong>at</strong>e against your own documentedprocesses <strong>and</strong> QMS.4.15 Continually review <strong>and</strong> document your qualityplans, initi<strong>at</strong>ives, internal assessments, externalassessments & results. Make decisions based onfacts.©2008 College of <strong>American</strong> P<strong>at</strong>hologists. All rights reserved.Every number is a life.©2008 College of <strong>American</strong> P<strong>at</strong>hologists. All rights reserved.Every number is a life.Implement<strong>at</strong>ion RoadmapCAP Approach to ISO 15189Str<strong>at</strong>egy & Planning QMS Development Audit MaintenanceQMSIdentifyIdentify goalsreadiness & Marketteamobjectives & metricseduc<strong>at</strong>ionassessmentEtblih EstablishstakeholderMgmt.DevelopcommitmentDevelopimplement<strong>at</strong>ionDevelop & mapAssemble InternalReviewAppointCre<strong>at</strong>eCorrectiveInternalquality policy,steering planCore processes Document<strong>at</strong>ion quality Audit ActionAuditsobjectivesmanualReviewcommittee& metricsgoals &Changereviseman<strong>age</strong>mentBuild supportmetricsstr<strong>at</strong>egyfor processesSurveillance• Document<strong>at</strong>ion• Training• CompetenciesCre<strong>at</strong>e document & records control systemsConduct training on process mapping,process improvement, document<strong>at</strong>ion©2008 College of <strong>American</strong> P<strong>at</strong>hologists. All rights reserved.Conduct training on internal audit,man<strong>age</strong>ment review,root cause analysisEvery number is a life.No m<strong>and</strong><strong>at</strong>ory timeline• All assessments are announced with a defined <strong>age</strong>nda th<strong>at</strong> is agreed toby <strong>the</strong> client• Schedules <strong>and</strong> site visits are coordin<strong>at</strong>ed <strong>and</strong> based on when <strong>the</strong> clientis ready3 Year Accredit<strong>at</strong>ion CycleCAP Assessors trained in ISO 15189, RABQSA (Registrar Accredit<strong>at</strong>ionBoard (RAB) & Quality Society of Australasia (QSA) in Sydney)• Account executive approach, supporting <strong>the</strong> client for all m<strong>at</strong>erials<strong>and</strong> communic<strong>at</strong>ions throughout <strong>the</strong> <strong>accredit<strong>at</strong>ion</strong> processEduc<strong>at</strong>ional approach• CAP offers <strong>the</strong> unique opportunity for optional:• Introductory Visits• Gap Assessments• Pre Assessments©2008 College of <strong>American</strong> P<strong>at</strong>hologists. All rights reserved.Every number is a life.10
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