1. 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 MEDICINE 6825 16TH STREET NW, BUILDING 54 WASHINGTON DC 20306-6000

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 16 th ST NW, Washington, DC 20306-6000 –Email attachment: rapisurag@afip.osd.mil or wisec@afip.osd.mil or Brownga@afip.osd.milrapisurag@afip.osd.mil wisec@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 Cancellation Timetable 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 16 th 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 Certificates DIRECTOR’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 PICTURE Director’s Qualifications CertifiedDirector PathologistCLIA, CAP, CLIP MD/DO/DPMCLIA, CAP, CLIP PhDCLIA, CAP, CLIP PhD –Not certifiedCLIA - MC only, CAP Master’s degreeCLIA – MC only Bachelor’s degreeCLIA- MC only

18. CLIP Certificates Director’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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