CAP PT & ACCREDITATION (LAP) CLIP CERTIFICATES OVERVIEW

1. 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 RAPISURAG@AFIP.OSD.MIL

2. CAP PT & LAP • CAP PT and Accreditation are centrally funded via CCLM through CAP contract. • CAP contract is renewed every calendar year

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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.

10. 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

11. 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

12. 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.

13. 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.

14. 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

15. 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

16. 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.

17. BIG PICTUREDirector’s Qualifications

18. 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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