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CENTER FOR CLINICAL LABORATORY MEDICINE 6825 16TH STREET NW, BUILDING 54 WASHINGTON DC 20306-6000. CAP PT & ACCREDITATION (LAP) CLIP CERTIFICATES OVERVIEW. HMC GERRY RAPISURA, MT(ASCP) PROGRAM MGR, NAVY DoD-CLIP PH: (202) 782-2467 FAX: (202) 782-6022 DSN: 662

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cap pt accreditation lap clip certificates overview

CENTER FOR CLINICAL LABORATORY MEDICINE

6825 16TH STREET NW, BUILDING 54

WASHINGTON DC 20306-6000

CAP PT & ACCREDITATION (LAP) CLIP CERTIFICATESOVERVIEW

HMC GERRY RAPISURA, MT(ASCP)

PROGRAM MGR, NAVY DoD-CLIP

PH: (202) 782-2467

FAX: (202) 782-6022

DSN: 662

[email protected]

cap pt lap
CAP PT & LAP
  • CAP PT and Accreditation are centrally funded via CCLM through CAP contract.
  • CAP contract is renewed every calendar year
cap proficiency testing pt
CAP Proficiency Testing (PT)
  • Every year in August or early September, Lab enrolled in CAP PT will received:
    • a preprinted order form
    • product catalog
    • Cover Letter
      • PT ordering instruction
      • READ IT.
cap pt order
CAP PT ORDER*
  • Review PT preprinted order form carefully and make changes to fit your lab needs.
    • Make changes if applicable on the Lab Info and Shipping Info block.
      • Write changes inside the square blocks.
    • To delete PT:
      • Put zero in “Revised Quantity” column
      • Do not line crossed
    • To add PT:
      • Use the blank order form
      • List product code, description and quantity
      • Disregard the Unit Price & Ext Amount column

* Example: See Attachment A

cap pt order5
CAP PT Order
  • Lab without preprinted order form due to:
    • Lost in the mail
    • Received but:
      • Discarded
      • Misplaced
      • Set it aside because the deadline was two months away and can’t find it now that its overdue.
  • Use the blank order form located at the back of the CAP Survey or Excel catalog.
  • Call CAP (1-800-323-4040) to request a replacement order form or catalog
cap pt order6
CAP PT Order
  • When order is reviewed, edited and completed, submit (hopefully before the deadline-usually the first week of November) to CCLM via one of the following:
cap pt order7
CAP PT Order
  • PT changes (Add or Cancel) after submission of initial order to CCLM and throughout the contract period
    • Mail, Fax or preferably Email changes to corresponding Program Manager
      • Change request must includes
        • CAP number
        • Product Code
        • Quantity
pt addition or cancellation timetable
PT Addition or CancellationTimetable
  • Addition:
    • Anytime
    • Current event: Can be done within 10 days after scheduled shipment and depending on survey availability.
  • Cancellation:
    • Must be requested 30 days prior to shipment schedule.
    • Less than 30 days – still receive the current shipment.
slide9
PTES
  • Proficiency Testing Exceptional Summary (PTES) Report – Unsatisfactory PT performance
    • All Failures: Must submit response to CAP
    • Second or more failure in three consecutive or within four mailings: Must submit investigation and corrective action taken to CCLM, Armed Forces Institute of Pathology, 6825 16th ST NW, Washington, DC 20306
      • Documentation send to CAP are acceptable for CCLM
      • Failure to response: Suspension or revocation of CLIP certificates and/or CAP accreditation or cease testing order from CAP.
  • More on PTES later.
cap accreditation lap
CAP ACCREDITATION (LAP)
  • CAP accreditation is centrally funded by CCLM through CAP contract
    • No command expenses except for the Coffee and Donut
  • Accreditation other than CAP and want to switch to CAP:
    • Notify CCLM respective Program Manager at least 9 months prior to expiration of current accreditation.
    • After CCLM approval (addition to the contract), coordinate with CAP for all the required application forms.
      • Make sure to add Point of Care testing in your CAP LAP application – means that all your CLIP certificates are listed
accreditation
Accreditation
  • High and Moderate (Non-waived) complexity lab must be inspected and accredited by civilian accrediting agency (CAP, JCAHO, COLA, ETC)
  • PPM and Waived
    • No requirements for accreditation inspection.
    • CCLM strongly recommend inspection for CLIP certificate renewal
renewal clip certificate
RENEWAL: CLIP Certificate
  • Types of CLIP certificate:
    • High Complexity
    • Moderate Complexity
      • PPM – Provider Performed Microscopy
    • Waived
  • CLIP Certificates are automatically renewed when CCLM received the accreditation inspection report from CAP.
    • Accreditation report must include Point Of Care testing or CLIP# to renew Waived and PPM.
    • To renew non-inspected POC site must submit a memo to CCLM stating site complies with the DoD CLIP AFIP PAM 40-24 regulations AND Compliance Self-Assessment Checklist – See Attachment B & C.
changes clip certificate
CHANGES: CLIP Certificate
  • Laboratory must notify CCLM within 30 days of any change in:
    • Director’s name, rank, status
    • Location
    • Name of the Laboratory
    • Testing sites
  • Notify CCLM via email or memo to update CLIP certificate. Army – more on this later.
updates clip certificate
UPDATES: CLIP Certificate
  • The request to update CLIP certificates must include:
    • CLIP #
    • New Director’s name, rank, status, SSN if applicable
      • Director’s Curriculum Vitae (CV)
    • CLIP Application form for waived and PPM (Army)
    • Any changes required
clip certificates director s qualifications
CLIP CertificatesDIRECTOR’S QUALIFICATIONS
  • High and Moderate:
    • Pathologists
    • MD
      • 1 yr (2 years for High) experience
      • Certified either hematology or hemo oncology
      • 20 CME in lab operation and administration
    • PhD
      • Doctoral degree in Chemical, Physical, Bio, Clinical Lab Science
      • Certified ABMM, ABCC, ABB, ABMLI
      • 1 yr ( 2 yrs High) experience
clip certificates director s qualifications16
CLIP Certificates DIRECTOR’S QUALIFICATIONS
  • PPM Directors Qualification
    • Physician
    • Midlevel Practitioner (Midwife, Nurse Practitioner, PA)
    • Dentist
    • Anybody qualified for High and Moderate
  • Waived
    • All of the above.
  • Master and Bachelor’s Degree are NOT qualified in any complexity certificate.
clip certificates director s max of lab sites
CLIP CertificatesDirector’s Max # of Lab Sites
  • Director can direct no more than:
    • High complexity: 5 sites or certificates with single site
    • Moderate complexity: 5 sites or certificates with single site
    • PPM: 5 sites or certificates with single site
    • Combination of High, Moderate &PPM: 5 sites or certificates with single site
    • Waived: No Limit
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