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Notification to CAP-Accredited Laboratories: Personnel Update

To College of American Pathologists (CAP) Accredited Laboratories:

As a service to CAP-accredited laboratories, the CAP is providing information and resources regarding a change that will be made in the 2016 Checklist edition, scheduled to be released August 17, and to the Laboratory Personnel Evaluation Roster form. A new checklist requirement, GEN.54025, will be added to the Laboratory General Checklist to help ensure that personnel records are complete and that qualified individuals are filling the required roles. The updated personnel roster form was redesigned with input from CAP-accredited laboratories. It has a different format and further aims to ensure that you have the right personnel performing the right types of functions.

The new requirement for the 2016 Checklist edition is as follows:

GEN.54025 Laboratory Personnel Evaluation Roster Phase II

The Laboratory Personnel Evaluation Roster is current and accurate and is audited by the laboratory director or designee at least annually for nonwaived testing personnel and personnel fulfilling supervisor roles.

NOTE: The laboratory's audit of the laboratory personnel evaluation roster must include a review of a mixture of the following types of personnel:

  • All nonwaived testing personnel hired within the last 12 months (laboratory and non-laboratory)
  • Laboratory and non-laboratory (POC, PPT, Radiology, Respiratory, etc.) personnel
  • Full and part-time nonwaived testing personnel on all shifts and throughout all departments
  • Personnel fulfilling supervisory roles (e.g. laboratory director, technical supervisor, staff pathologist)

Personnel performing any CLIA-defined duty must be listed on the roster. Personnel performing waived testing only or whose duties are limited to phlebotomy, clerical work or specimen processing are not required to be listed on the Laboratory Personnel Evaluation Roster. Histology personnel that do not perform high-complexity testing are also excluded. All grossing performed in histology is considered high complexity testing.

Evidence of Compliance:

✔ Records of completed rosters accurately reflecting personnel AND

✔ Records of annual audits performed by the laboratory director or designee

Laboratories will be assessed for compliance with GEN.54025 beginning with on-site and interim self-inspections using the 2016 edition of the checklist. The updated personnel roster form will be provided with application materials starting in August 2016 and is available electronically below, along with the following resources:

The above documents are also available on the CAP website in e-LAB Solutions Suite (login required) under “Accreditation Resources/Forms and Instructions.”

Questions? Contact us at 800-323-4040 or accred@cap.org.