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

RAPISURAG@AFIP.OSD.MIL

CENTER FOR CLINICAL LABORATORY MEDICINE6825 16TH STREET NW, BUILDING 54

WASHINGTON DC 20306-6000

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)

• 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*

• 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 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 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:– Fax: Fax# (202) 782-6022 DSN:662– Mail: CCLM, ATTN: Navy or Army or Air Force DoD

Program Manager, AFIP, 6825 Room G134 16th ST NW, Washington, DC 20306-6000

– Email attachment: rapisurag@afip.osd.mil or wisec@afip.osd.mil or Brownga@afip.osd.mil

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 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.

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 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

• 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• 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

• 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

• 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 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 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.

BIG PICTUREDirector’s Qualifications

Certified Director

Pathologist CLIA, CAP, CLIP

MD/DO/DPM CLIA, CAP, CLIP

PhD CLIA, CAP, CLIP

PhD –Not certified CLIA - MC only, CAP

Master’s degree CLIA – MC only

Bachelor’s degree CLIA- MC only

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

???????

Thank you