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Policy Manual Main Page
General Policy Table of Contents

Appendices

  1. Accreditation and Certification documents
    1. CAP
    2. CMS (CLIA)
    3. JCAHO
  2. Surgical Case Review Criteria
  3. Quality Management
    1. Quality Management &
      Assessment Log
    2. Quality Management Tracker
  4. Examples of Test Requisitions
    1. CRIS Downtime Requisition
    2. LP Outside Tissue Exam
      (Submitted case) Requisition
    3. Request for Polymerase
      Chain Reaction (PCR) Analysis
    4. Request for In Situ Hybridization
      (ISH) Analysis
    5. Example of CRIS Request for
      Anatomical Pathology
    6. Ultrastructural Pathology
      (Electron Microscopy) Request
  5. Biannual Water Quality Control Worksheet
  6. Organizational Chart
  7. Designation of Duties of Director
    of Clinical Operations
  8. Policy Statement of the Prevention
    of Sexual Harassment
  9. Memo Regarding Time and Attendance
  10. Continuing Education Log Worksheet

Expanded Site Map

LABORATORY OF PATHOLOGY ONLINE POLICY MANUAL

OVERVIEW OF LABORATORY OF PATHOLOGY

Our mission

The mission of the Clinical Services of the Laboratory of Pathology of the National Cancer Institute is to achieve the highest level of quality in diagnostics, education and research.

  • Diagnostics : We take responsibility for all anatomic pathology services for all categorical institutes of the NIH, the Warren G. Magnuson Clinical Center, as well as others who seek our expertise through consultation. The goal is to provide the highest quality and most accurate diagnostic interpretation in the most efficient manner. This goal is supported by a commitment to continuous Quality Management.
  • Education: Through the participation in clinical and research conferences and training of residents and fellows, we provide leadership in anatomic pathology. As an organization, which applies state-of-the-art technology to tissue and cell-based diagnostics, we share our expertise and teaching with the clinical and scientific community.
  • Research: We support the research mission of the NIH through our support of clinical research protocols and by seeking to apply leading edge technology to diagnostic questions. In this endeavor we value originality, scientific integrity and ethical behavior, thereby setting a high standard for pathology research excellence for ourselves and for the international pathology community

Our vision


The Laboratory of Pathology of the National Cancer Institute is a partner with the clinical and research community at the National Institutes of Health. By continuing to expand the scope of our expertise and by incorporating the newest tools of diagnosis, training, and research, our goal is to be a globally recognized center of excellence for clinical diagnostics, disease research, and pathology education.

Departmental philosophy

In our ongoing management of our programs, and in our strategic planning process, we have been guided by a set of core values that define our organizational culture. These are:
  • To respect the contributions and diversity of the people in our workplace.
  • To promote excellence in patient care and clinical trial support.
  • To hold ourselves to the highest standards of ethical conduct.
  • To maintain a commitment to a high quality work life.
  • To be good stewards of our resources.

Accreditation and Certification

The Laboratory of Pathology's clinical sections are accredited by the College of American Pathologists (CAP) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). LP is certified pursuant to the Clinical Laboratory Improvement Amendments (CLIA) by the Center for Medicare and Medicaid Services (CMS). Documentation is provided in Appendix A of this manual (see menu on left) and may be distributed to anyone who requests the information.

Educational Programs

The Accreditation Council for Graduate Medical Education accredits LP for its residency program in Surgical Pathology and fellowship programs in Cytopathology and Hematopathology. LP has a strong commitment to education and has several other research fellowships throughout the department.

Policy on Compliance with CAP Terms of Accreditation

As part of its compliance with the terms of CAP accreditation, the Laboratory of Pathology will inform CAP immediately if any of the following events occur:

  1. Investigation of the Laboratory of Pathology by a Government entity (this will apply only to investigations of the laboratory’s clinical services and not to investigation or queries made to the NCI or the NIH as a whole).

  2. Adverse media attention related to the clinical performance of the Laboratory of Pathology.

  3. Changes in the test menu of the Laboratory of Pathology.

  4. Change in location of the Laboratory of Pathology’s offices and labs.

  5. Change in directorship of the Laboratory of Pathology.

When a new test is to be brought into practice it will be the responsibility of the individual lab directors (section chiefs) to notify the Laboratory Director for the Laboratory of Pathology who will notify CAP prior to beginning patient testing. New testing should not begin before CAP is notified. The Laboratory Director will notify CAP in the event that any of the other conditions are met.

Last Updated 6/23/2009 2:38:29 PM
 
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