Mohs/Histology Laboratory Compliance Manual

Transcription

1 Mohs/Histology Laboratory Compliance Manual Do Not Remove From Laboratory

2 INDEX CLIA Quality Control Program page 2 Maintenance Record-Microscope page 6 Cryostat Protocol page 7 Maintenance Record-Cryostat page 8 Media or Stain Log page 9 Refrigerator Protocol page 10 Maintenance Record-Refrigerator page 11 Repair Companies page 14 Mohs page 16 Histopathology page 54 Job Descriptions page 90

3 Quality Assurance The lab director will monitor all aspects of the laboratory and make certain that all testing complies with the individual testing policy and procedure protocols. Modifications and updates Date / Director Signature Changes 1

4 Quality Control Program It is the policy of Dr. laboratory to maintain a Quality Control Program to insure accuracy of results reported. All employees of this laboratory must be familiar with and adhere to all the policies herein stated with regard to quality control. The Quality Control Program involves monitoring the facilities; test methods and equipment, reagents, materials and supplies; procedure manual; method verification; equipment maintenance; calibration and calibration verification; control procedures; remedial actions; and maintenance of quality control records. Facilities The facilities of this laboratory consists of approximately square feet of laboratory space. The environment in the working area of the laboratory will be controlled by the commonly used heating, air-conditioning and ventilation equipment used throughout the entire medical office, which will maintain a working temperature of 65 to 76 degrees Fahrenheit. Proper lighting will be monitored at least daily. Any burntout bulbs will be replaced as soon as reasonably possible with new bulbs. The Laboratory Director will ensure that proper ventilation systems are maintained throughout the laboratory. Test Methods, Equipment, Reagents, Materials and Supplies The laboratory Director will be responsible for making the final decision on the test system, equipment and methodologies used in the laboratory. The Laboratory Director will ensure that proper test validation has been performed on all tests performed in the laboratory before reporting any patient test results. The Laboratory Director will decide the number of tests performed to validate the instrument or test system. All equipment within the laboratory will be properly maintained according to the manufacturer s specifications. The Laboratory Director will be responsible for ensuring that all maintenance and repair of equipment are completed in a timely fashion. All maintenance and repairs will be recorded and maintained by the laboratory personnel and will be reviewed by the Laboratory Director on a periodic basis. The laboratory will maintain appropriate and sufficient supplies for the type and volume of testing conducted by the laboratory. The Laboratory Director will be responsible for maintaining an inventory of all supplies needed for the proper functioning of the laboratory. Temperature logs and graphs will be maintained for ambient room air and refrigerator and freezer temperatures when necessary. Temperatures will be taken by an employee in the laboratory and recorded. If a temperature is outside the desired range, the Laboratory Director will be notified as soon as possible, and before any patient result is reported. Appropriate corrective action will be taken and documented. It is the responsibility of 2

5 the Laboratory Director to determine the severity of the problem and the effect on the testing process. All reagents, solution, culture media, control materials, calibration materials and other supplies will be labeled to indicate: 1) Identity and, when significant, titer, strength or concentration. 2) Recommended storage requirements. 3) Preparation and expiration dates. 4) Safety data. 5) Other pertinent information. Reagents, solutions, culture media, controls, calibration materials and other supplies are not used when they have exceeded their expiration dates, have deteriorated or are of substandard quality. Verification of Method Performance Specifications The laboratory will establish performance specifications for any new test methodology instituted after September 1, The laboratory will verify the performance specifications for each new method based on: 1) Accuracy; 2) Precision; 3) Analytical sensitivity; 4) Analytical specificity to include interfering substances; 5) Reportable range of patient test results; and 6) Any other performance characteristic required to test performance. The laboratory will document verification of applicable test performance specifications and will maintain such documentation for the life of the methodology plus five years. Equipment Maintenance The Laboratory Director will ensure that periodic equipment maintenance and function checks are performed as required by the manufacturer or determined by the Laboratory Director. Proper records will be maintained to indicate the tests performed. These 3

6 records will be maintained for the life of the instrument plus five years. Maintenance instructions for microscopes (see page 5) cryostats (see page 7), refrigerators (see page 10) should be documented. Calibration and Calibration Verification All instruments in the laboratory will be calibrated according to the following guidelines: 1) When a lot number of a reagent changes. 2) As recommended by the manufacturer. 3) When an out of control situation exists and cannot be resolved by other means. 4) When major preventive maintenance, or replacement of critical parts which may influence test performance, is done. 5) At least every six months. Calibration verification will be performed according to the recommendations of the manufacturer using calibration materials specified by the manufacturer. Control Procedures The control procedures set forth in the procedures manual will be followed for each individual test. Remedial Actions Any remedial action taken by the laboratory will be documented on the Corrective Action Request Form (see Corrective Action request Form, page 15) and reviewed by the Laboratory Director. The records will be kept for a two-year period or until an inspection occurs. 4

7 Equipment Quality Control for Microscopes (State frequency of activity in spaces below) 1) Microscope stage and ocular eye pieces are to be cleaned Stage is to be cleaned with alcohol or similar cleaner and ocular eye pieces are to be cleaned with lens paper. 2) Grounding check is monitored 3) Notify the supervisor if any problems occur with instrumentation. 4) Every action is documented on the maintenance record form. Protocol for Dealing with a Nonfunctioning Microscope (Check applicable statement) If, during an examination of specimens, the microscope should become nonfunctioning: A back-up microscope is available at all times. The test will be postponed until the microscope is required. Other (Specify): 5

8 Maintenance Record for Microscopes Date of maintenance activity must be recorded and initialed. Stage & Oculars Cleaned Grounding/Cleaning Date: Initial Date: Initial 6

9 Equipment Quality control for Cryostats (State frequency of activity in spaces below) 1) Temperature is recorded daily and documented. 2) Temperature range is 20 degrees C to 30 degrees C. 3) Corrective action is taken and documented if temperature exceeds range. 4) Defrost of machine is done. 5) Interior is cleaned using absolute alcohol, while wearing gloves. 6) Cryostat knives are sharpened as needed; or use disposable blades. 7) Air filter is cleaned as part of the maintenance every. 8) Thermometer check is done. 9) The fly wheel and moving components on the cryostat are oiled, as recommended by the manufacturer, every. 10) Preventive maintenance and grounding check are done every. 11) If any accidents occur while working with the cryostat, report to your supervisor and the incident will be documented. 12) Notify supervisor if any problems occur with instrumentation. 13) Every action is documented on the maintenance record form. Protocol for Dealing with a Nonfunctioning Cryostat 1) The cryostat is checked for proper functioning. 2) If the unit does not work, the patients who have been scheduled for surgery on that day will be called immediately and surgery canceled. 3) The service contract company will then be called for repair. Repair or replacement is guaranteed within 24 hours. 4) Instruction manuals are to located in the laboratory. 7

10 Maintenance Record for Cryostats Month Year Activity Clean Thermometer Moving Clean Preventive Defrost Problems/ Interior Check Components Air Maintenance Machine Supervisor Filter Attention

11 Media or Stain Receipt Log Media or Manufacturer Batch Date Stain Number Opened Condition Action taken if any Notes: 9

12 Equipment Quality Control for Refrigerators (State the frequency of activity in spaces below) 1) Read and record internal temperature daily. Optimum temperature for the refrigerator is 2 degrees C to 8 degrees C (35.6 degrees F to 46.4 degrees F) and for the freezer is 5 degrees C or colder (23 degrees F or colder). 2) Check door gasket seal every. 3) Defrost and clean interior every. 4) Grounding check is monitored every. 5) Notify the supervisor if any problems occur with instrumentation. 6) Every action is documented on the maintenance record form. 10

13 Temperature Monitor Log for Refrigerators, Freezers, Cryostats Month Year (Insert temperature in appropriate box) Date Room Refrigerator Freezer Cryostat Initials

14 Maintenance Record for Refrigerators (Date of maintenance activity must be recorded and initialed.) Check Door Gasket Seal Defrost/Clean Check Grounding Every six months Initial Every three months Initial Every three months Initial 12

15 Laboratory Quality Control for Hematoxylin and Eosin Month Year Nuclei Cytoplasm Thickness Section Day Slide # Blue Pink/Red 5-10 Microns Complete Comments Initial Monthly Review By: Date: 13

16 Repair Service Companies for Laboratory Equipment (State Name, Address and Phone numbers of the repair service company in the spaces below) Microscope: Cryostat: Fume Hood: Refrigerator: 14

17 Corrective Action Request Form Quality Assurance Program Corrective Action Request Form Originator: Date: Responsible Person: Area of Concern: Nature of Problem: Signature Corrective Action: Signature Reviewed By: Date: Discussed at Staff Meeting Yes No Date: Comments: Signature 15

18 Proficiency Testing At the current time, there is no formal or approved procedure for proficiency testing of Mohs surgical laboratories. There is discussion that the American College of Mohs Micrographic Surgery and Oncology is developing such a program. When that program is developed, this laboratory will be pleased to participate. 16

19 Laboratory Procedure Histopathology Mohs Surgery Laboratory: Director: Because there may be some variation in the test procedures for histopathology Mohs surgery (e.g., stains used) you will need to thoroughly review the following Laboratory Procedure Manual on histopathology Mohs surgery and modify or rewrite to conform with the practices in your laboratory. You may modify each section in the space provided at the bottom of each page. 17

20 Record of Changes All changes should be made in the space provided or on the corresponding facing page. Each change or notation should be referenced to the appropriate paragraph number and signed by the Laboratory Director. Review Policy This procedure manual is reviewed by the Laboratory Director annually and at other times as required by major changes in procedure or other circumstances affecting laboratory performance of the test. Review by Laboratory Director Date: Signature: Date of first use of these procedures: Date of last use of these procedures: Copies of all procedures must be retained for two years after last date of use. 18

21 Histopathology Mohs Surgery Review by Laboratory Director 1) Principle of Test 2) Diagnostic Value 3) Specimen Requirements: Patient preparation Specimen collection Slide/specimen rejection Specimen handling, storage, preservation and identification 4) Materials and Reagents: Materials and reagents used Preparation and labeling Storage, use and handling 5) calibration 6) Quality Control 7) Test Procedure 8) Calculations 9) Reading and Reporting Reading results Reportable range Reference range Critical value reporting Procedures for panic values 19

22 Reporting results 10) Procedure Notes 11) Limitations of Procedure 12) Remedial Actions 13) References 20

23 Histopathology Mohs Surgery Reviewed by Director 1. Principle of Test 1.1 Provides microscopic data from tissue samples for correlation with clinical data. Allows for precise margin control excision of contiguously growing cutaneous neoplasms. 21

24 2. Diagnostic Value 2.1 Assessment of therapy, such as completeness of tumor removal. 22

25 3. Specimen Requirements 3.1 Patient Preparation The patient is appropriately prepared for the type of surgical procedure performed to obtain the specimen for histologic examination. 23

26 3.2 SPECIMEN COLLECTON PROCEDURE Mohs micrographic surgery Debulking of tumor Removal of a thin layer of tissue with a 1 3 mm margin surrounding the tumor. A thin specimen allows the tissue to be mounted so that the lateral and deep margins can be examined in the same plane under the microscope after frozen section processing. Tissue is precisely oriented on the patient prior to removal. The layer of tissue removed is sectioned and the edges of the specimens are marked with colored dyes. The dyes can be easily identified in frozen sections and permit accurate orientation of excised tissue. A detailed map is made to correlate with the tissue removed. 24

27 3.3 SLIDE/SPECIMEN REJECTION Incorrectly labeled specimen, e.g., wrong patient. 3.4 SPECIMEN HANDLING, STORAGE, PRESERVATION AND IDENTIFICATION Designate a small contamination area within the laboratory to handle specimens Gloves must be worn to handle all specimens Mohs surgeon brings tissue to laboratory technician with Mohs map and proper identification Mohs surgeon reviews specimen with laboratory technician, noting site and instructing if there is a vertical frozen section. 25

28 3.4.5 Laboratory technician notes time and logs it, with his/her name on Mohs map Patient name, site, date, Mohs surgeon and laboratory technician is written on Mohs log, along with total number of slides processed If a vertical frozen section has been ordered by the Mohs surgeon, this is written in the vertical frozen section log, and a pathology sheet is filled out with patient name, site, age, account number, date, Mohs surgeon and laboratory technician Specimens are frozen in correct order in Cryostat. 26

29 3.4.9 Laboratory technician will cut frozen sections and stain. Slides are labeled with number, full patient name, date and type After cover slips are applied, the labeled slides with Mohs map are brought to Mohs surgeon for evaluation Slides should be maintained for 10 years Specimens will be disposed of according to federal, state and local law. 27

30 4. Materials and Reagents 4.1 MATERIALS AND REAGENTS USED Mounting compound or embedding medium Cryostat (specify) Histofreeze or comparable tissue freezing aerosol Glass slides or coated glass slides Staining materials (See pages 36 & 37) Dyes for marking tissue Cover glass 28

31 4.2 PREPARATION AND LABELING Liquid reagents may be transferred to smaller containers for that particular reagent Dilutions of stock solutions should be performed under a ventilation hood for volatile materials All reagents are to be labeled with the following information: reagent dilution date prepared technician temperature for storage (if not room temperature) 29

32 4.3 STORAGE, USE AND HANDLING (check below where appropriate) Manufacturer s control checks of media are not provided; therefore, the laboratory will check each batch or shipment of reagents when opened or prepared for positive and negative reactivity as well as sterility. The laboratory will also check media for their ability to support growth, and, as appropriate, selectivity, inhibition and/or biochemical response. All information will be properly documented. Manufacturer s control checks of media are provided and the manufacturer s product insert specifies that the manufacturer s quality control checks meet the National Committee for Clinical Laboratory Standards for media quality control. The laboratory will document the physical characteristics of each medium to indicate that it is not compromised and report any deterioration to the manufacturer. The laboratory will follow the manufacturer s specifications for using media. The laboratory will also check each batch or shipment of reagents when opened or prepared for positive and negative reactivity. All information will be properly documented. 30

33 4.3.2 Reagents are stored according to manufacturer s instructions and temperature logs are maintained as appropriate Do not use reagent after expiration date Discard and do not use unlabeled reagents Material safety data sheet are located Reagents are disposed of according to federal, state, and local laws. 31

34 5. Calibration Temperature and time-controlled equipment is calibrated daily or according to the manufacturer s recommendations Daily temperature charts of all temperature-sensitive equipment are maintained. Examples: refrigerators, freezers, tissueprocessing equipment, cryostat Ph meters are calibrated with each use While cutting frozen sections, the cryostat will be kept within a range of 20 degrees C to 30 degrees C. 32

35 6. Quality Control (Check where applicable) All slides, paraffin blocks and reports are available for review by laboratory accrediting agencies Reports from cases sent for consultation are maintained as part of the record Reports of cases presented at conferences and scientific meetings and in scientific publications are maintained as part of the record The laboratory participates in the reciprocal reading of slides with A control slide will be made and evaluated each day that a frozen section is prepared. A record of the control slide will be maintained. 33

36 7. Test Procedure 7.1 PROCEDURE FOR SECTIONING THE SPECIMEN The specimens are brought into the laboratory by the Mohs surgeon and given directly to the laboratory technician. The tissue is presented with the epidermis, or the most superficial side of the tissue, facing up. The tissue specimens are flattened and mounted on a cryostat object disc using mounting compound or embedding medium. The specimens are mounted so that the lateral and deep margins will be in the same plane when sectioned. The cryostat object disc is placed in a cryostat for freezing. Histofreeze or a comparable tissue freezing aerosol may be used to expedite freezing. The tissue is then cut into 4 10 micron sections in a cryostat, which is kept within a range of 20 degrees C to 30 degrees C. 34

37 Sections are mounted on glass slides. These may be coated with Poly-1-Lysine, egg albumin or other substances to help ensure that the tissue adheres to the slides. After cutting, slides are handled according to the procedure outlined under staining techniques. Do not touch other objects in rooms while wearing contaminated gloves. Wipe outside surface of the cryostat with bleach. Wash hands after cutting frozen sections. All tissue disposed of are treated as biohazard waste according to federal, state and local laws. 35

38 7.2 STAINING H AND E OF FROZEN SECTIONS This procedure is to be used when sections are stained by hand and not when an automated stainer is used Fix in acetone 100% 30 sec Drying time 20 sec Gill s #3 hematoxylin * 60 sec Rinse in warm tap water until water runs clear Eosin Y alcoholic ** 1 dip % ETOH 20 dips % ETOH 20 dips 36

39 % ETOH 20 dips Hisoclear *** 20 dips Histoclear 20 dips Histoclear 20 dips Apply coverslip * Hematoxylin (Harleco Brand) leaves least amount of background residue ** Eosin Y *** Histo-Clear (or any xylene substitute) If the local tap water is not sufficient for bluing, the following may be used: Dip in acid alcohol for 15 seconds made by adding four drops hydrochloric acid to container filled with 70% alcohol. Rinse in tap water. Dip in ammonia water for 5 seconds made by adding four drops of ammonium hydroxide to container filled with tap water. Rinse in running tap water for 2 minutes. Proceed to Eosin. 37

40 7.3 STAINING H & E OF FROZEN SECTIONS This procedure is to be used with the Shandon Linistain automated stainer % alcohol and formalin 30 sec Hematoxylin * 15 sec Hematoxylin * 15 sec Water wash 15 sec Water wash 30 sec % acid alcohol 15 sec Water wash 15 sec. 38

41 7.3.8 Water wash 15 sec Ammonia water 15 sec Water wash 30 sec % alcohol 15 sec Alcoholic Eosin 15 sec % alcohol 15 sec % alcohol 30 sec % alcohol 15 sec. 39

42 % alcohol 30 sec Xylene substitute 30 sec Apply coverslip * Harris s modified hematoxylin which contains acetic acid. ** The acid alcohol is made by adding four drops hydrochloric acid to the 15-second container filled with 70% alcohol. *** The ammonia water is made by adding four drops of ammonium hydroxide to the 15-second container filled with tap water. **** Eosin Y 40

43 7.4 STAINING TOLUIDINE BLUE OF FROZEN SECITONS This is a procedure to be used with the Shandon Linistain automated stainer Fix in absolute alcohol 30 sec Running water 60 sec Toluidine blue 0.8% aqueous * 30 sec Toluidine blue 0.8% aqueous * 30 sec. 41

44 7.4.5 Running water 30 sec Running water 30 sec % alcohol 30 sec Absolute alcohol 30 sec Absolute alcohol 30 sec Absolute alcohol 30 sec. 42

45 Clearant (xylene substitute) 30 sec Clearant (xylene substitute) 30 sec Clearant (xylene substitute) 30 sec Clearant holding baths Apply coverslip * The Toluidine Blue is made by adding 0.8 grams Toluidine Blue O Powder to 100 cc deionized water. Mix well. Filter before using. 43

46 7.5 STAINING TOLUIDINE BLUE OF FROZEN SECTIONS This procedure is to be used when sections are stained by hand and not when an automated stainer is used Fix in absolute alcohol 30 sec Wash in water until all the mounting media is dissolved, about 1 minute 60 sec Toluidine blue 0.8% aqueous * 60 sec Rinse in tap water to remove excess stain. 15 sec % alcohol 5 dips 44

47 % alcohol 5 dips Absolute alcohol 15 sec Absolute alcohol 15 sec Clearant (xylene substitute) 15 sec Clearant (xylene substitute) 15 sec Clearant (xylene substitute) 15 sec Apply coverslip * The Toluidine Blue is made by adding 0.8 grams Toluidine Blue O Powder (Fisher Scientific) to 100 cc deionized water. Mix well. Filter before using. 45

48 8. Calculations Not applicable. 46

49 9. Reporting and Reading Results 9.1 READING RESULTS Gross Not applicable for Mohs Surgery Microscopic A detailed report should be recorded which includes a description of the tumor and any unusual histologic features as well as a description of where any residual tumor is remaining after each layer of tissue is removed When performing Mohs surgery a map is used instead of a report to decide where any residual tumor is remaining. Notes are made on the map and/or is the record of any unusual histologic features. 47

50 9.2 REPORTABLE RANGE Not applicable 9.3 REFERENCE RANGE Not applicable 9.4 CRITICAL VALUE REPORTING Not applicable 48

51 9.5 PROCEDURES FOR PANIC VALUES Not applicable 9.6 REPORTING RESULTS The presence or absence of tumor and relationship to specimen margins should be recorded. When performing Mohs surgery this is recorded on the patient map. 49

52 10. Procedure Notes Not applicable. 50

53 11. Limitations of Procedure Mohs micrographic surgery is the most effective therapy for treating cutaneous neoplasm that spread by contiguous growth, but it has limited effectiveness in treating cutaneous neoplasms that grow in a noncontiguous manner. 51

54 12. Remedial Actions All out-of-control situations not resolved by a simple repeat analysis will be reviewed by the Laboratory Director as soon as practical after the event. The Laboratory Director will review the corrective action to assure that appropriate action was taken and proper procedures were followed. A Corrective Action Form will be filled out whenever a problem arises in calibration or an out-of-control situation is not resolved by simple repeat analysis. 52

55 13. Sources Cottel, W. I., Bailin, P.L., et al. Essentials of Mohs Micrographic Surgery, J. Dermatol, Surgery Oncol. 1988; 14:1, 11, Mikhail, G. R.: Mohs Micrographic Surgery, W. B. Saunders Company, Mohs, F. E., Chemosurgery: Microscopically Controlled Surgery for Skin Cancer. Springfield, IL, Charles C. Thomas, Roenigk, R. K., Mohs Micrographic Surgery, Mayo Clinic Proceedings 1988; 63: Marsing Mohs lab consulting services College of American Pathologists 53

56 Laboratory Procedure Manual Histopathology Laboratory: Director: Because there may be significant variations in the test procedures for histopatholy, e.g., stains used, and because many dermatologists may send specimens to an outside laboratory for preparation, you will need to thoroughly review the following Laboratory Procedure Manual for histopathology and modify or rewrite to conform with the practices in your laboratory. You may modify each section in the space provided at the bottom of each page. 54

57 RECORD OF CHANGES All changes should be made in the space provided or on the corresponding facing page. Each change or notation should be referenced to the appropriate paragraph number and signed by the Laboratory Director. REVIEW POLICY This procedure manual is reviewed by the Laboratory Director annually and at other times as required by major changes in procedure or other circumstances affecting laboratory performance of the test. REVIEW BY LABORATORY DIRECTOR DATE: SIGNATURE: Date of first use of these procedures Date of last use of these procedures Copies of all procedures must be retained for two years last date of use. 55

58 Histopathology Review by Laboratory Director 1. Principle of Test 2. Diagnostic Value 3. Specimen Requirements patient preparation specimen collection slide/specimen rejection specimen handling, storage, preservation and identification 4. Materials and Reagents materials and reagents used preparation and labeling storage, use and handling 5. Calibration 6. Quality Control 7. Test Procedure 8. Calculations 9. Reading and Reporting reading results reportable range reference range critical value reporting procedures for panic values 56

59 reporting results 10. Procedure Notes 11. Limitations of Procedure 12. Remedial Actions 13. Sources 57

60 Histopathology Review by Laboratory Director 1. Principle of Test 1.1 Provides microscopic data from tissue samples for correlation with clinical data. 1.2 Provides permanent data for concurrent and retrospective review. 58

61 2. Diagnostic Value 2.1 Provides microscopic data from tissue samples for correlation with clinical data. 59

62 3. Specimen Requirements 3.1 PATIENT PREPARATION The patient is appropriately prepared for the type of surgical procedure performed to obtain the specimen for histologic examination. 3.2 SPECIMEN COLLECTION PROCEDURE (Check appropriate surgical procedure) Punch biopsy Parallel incisional biopsy Excisional biopsy 60

63 3.3 CRITERIA FOR SPECIMEN REJECTON (Check applicable box) Not applicable specimen sent to laboratory for specimen preparation. (Indicate laboratory name, address, telephone number, contact person and documentation of laboratory s Quality Control procedures). OR Unlabeled specimen container Incorrectly labeled specimen container, e.g., wrong patient Specimens received in broken or crushed containers can occasionally be salvaged, but the conditions of receipt must be completely recorded Specimens received in the incorrect media or fixative can occasionally be salvaged, but the conditions of receipt must be completely recorded. 61

64 3.4 SPECIMEN HANDLING, STORAGE, PRESERVATION AND IDENTIFICATION Designate an area within the laboratory with good ventilation for initial handling of the specimens Gloves must be worn to handle all specimens Assign specimen identification number and label all worksheets, specimen containers and cassettes Record the patient s name, date, specimen identification number(s), anatomic sites and tests to be performed Record gross description of specimen and conditions of receipt. 62

65 3.4.6 Record description of sectioning of gross specimen Retain specimen containers until specimen is processed and finalized Retain excess gross tissue in fixative for (time), or longer if required by state law. Example: retain the excess tissue if only a small representative section was utilized for diagnosis Retain all slides and tissue blocks for 10 years or in compliance with state law Specimens will be disposed of according to federal, state and local laws. 63

66 4. Materials and Reagents 4.1 MATERIALS AND REAGENTS USED (Check applicable box) Not applicable specimen sent for processing to: (Indicate laboratory name, address, telephone number, contact person and documentation of laboratory s Quality Control procedures). OR Disposable gloves Laboratory aprons and lab coats Cutting board Forceps Scalpel blade/knife/razor blades for gross sectioning Tissue cassettes Automated processor for fixation, dehydration and paraffin embedding (specify) 64

67 Temperature-controlled paraffin embedding station (specify) Microtome Temperature-controlled water bath Glass slides Drying oven or microwave Staining dishes or automated staining processor (specify) Glass coverslips 10 percent buffered neutral formalin Ethyl alcohol Xylene (xylene substitutes may be used) Paraffin Staining reagents Mounting media 65

68 4.2 PREPARATION AND LABELING Liquid reagents may be transferred to smaller containers for particular reagents Dilutions of stock solutions should be performed under a ventilation hood for volatile materials All reagents are to be labeled with the following information: Reagent Dilution Date prepared Technician Temperature for storage (if not room temperature) 66

69 4.3 STORAGE, USE AND HANDLING (Check applicable box) Manufacturer s control checks of media are not provided; therefore, the laboratory will check each batch or shipment of reagents when opened or prepared for positive and negative reactivity as well as sterility. The laboratory will also check media for their ability to support growth, and, as appropriate, selectivity, inhibition and/or biochemical response. All information will be properly documented. Manufacturer s control checks of media are provided and the manufacturer s product insert specifies that the manufacturer s quality control checks meet the National Committee for Clinical Laboratory Standards for media quality control. The laboratory will document the physical characteristics of each medium to indicate that it is not compromised and report any deterioration to the manufacturer. The laboratory will follow the manufacturer s specifications for using media. The laboratory will also check each batch or shipment of reagents when opened or prepared for positive and negative reactivity. All information will be properly documented. 67

70 4.3.2 Reagents are stored according to manufacturers instructions and temperature logs are maintained, as appropriate Do not use reagent after expiration date Discard and do not use unlabeled reagents Material safety data sheets are located in MSDS section of the manual Reagents are disposed of according to federal, state and local laws. 68

71 5. Calibration (Check applicable box) Not applicable-specimens are sent for processing to: (laboratory name, address, telephone number & contact person). OR Temperature and time-controlled equipment is calibrated daily or according to the manufacturer s recommendations Daily temperature charts of all temperature-sensitive equipment are maintained. Examples: refrigerators, freezers, tissue-processing equipment, embedding stations, drying ovens, water baths ph meters are calibrated with each use. 69

72 6. Quality Control (Check applicable box) Not applicable-specimens are sent for processing to: (laboratory name, address, telephone number & contact person). OR The laboratory participates in the Quality Control Program administered by All slides, paraffin blocks and reports are available for review by laboratory accrediting agencies. 70

73 6.1.3 Reports from cases sent for consultation are maintained as part of the record Reports of cases presented at conferences and scientific meetings and in scientific publications are maintained as part of the records The laboratory participates in the reciprocal reading of slides with Other (specify) 71

74 7. Test Procedure (Check box below if applicable) Not applicable specimens are sent for processing to: (laboratory name, address, telephone number & contact person). OR 7.1 FIXATON (Check applicable box below) Tissue is usually fixed in 10% buffered neutral formalin for 2 to 4 hours for small specimens (4x4x4 mm) and up to 24 hours, depending upon size, for larger specimens Other fixatives may be used for special purposes (specify). 72

75 7.2 DEHYDRATION, CLEANING AND PARAFFIN INFILTRATION 60 minutes 10% buffered neutral formalin 60 minutes 10% buffered neutral formalin 60 minutes 50% ethyl alcohol 60 minutes 80% ethyl alcohol 60 minutes 95% ethyl alcohol 60 minutes 100% ethyl alcohol 60 minutes 100% ethyl alcohol 73

76 60 minutes 100% ethyl alcohol 60 minutes xylene (xylene substitutes may be used) 60 minutes xylene (xylene substitutes may be used) 60 minutes paraffin at 60 degrees C 60 minutes paraffin at 60 degrees C 74

77 7.5 TISSUE SECTIONING Tissue sections are cut at 4 microns on the microtome Tissue sections are floated on a water bath at 45 degrees C to 55 degrees C Tissue sections are picked up from the water bath onto clean labeled slides Slides are dried in the drying oven for 10 minutes at 55 degrees C. 75

78 7.5 STAINING Mayer s Hematoxylin and Eosin Procedure Fixation: Sections: 10% buffered neutral formalin Paraffin, 3 to 8 microns Solutions: Mayer s Hematoxylin Stock Solution Ammonium or Potassium alum Distilled water Hematoxylin Sodium iodate Citric acid Chloral hydrate 50.0 gm 1000 ml 1.0 gm 0.2 gm 1.0 gm 50 gm 76

79 Eosin Stock Solution Eosin Y, water soluble Distilled water 1.0 gm 100 ml Phloxine Stock Solution Phloxine B Distilled water 1.0 gm 100 ml Eosin-Phloxine working Solution Combine in a 1000 ml cylinder: Eosin stock solution 100 ml Phloxine stock solution 10 ml 95% ethyl alcohol 780 ml Glacial acetic acid 4 ml Note: This solution is good for one week. 77

80 7.5.1 Deparaffinize slides and hydrate to water 3 minutes xylene (xylene substitutes may be used: specify ) 3 minutes xylene (xylene substitutes may be used: specify ) 3 minutes xylene (xylene substitutes may be used: specify ) 1 minute 100% ethyl alcohol 1 minute 95% ethyl alcohol 1 minute distilled water minutes Mayer s hematoxylin solution minutes wash in lukewarm running water minute distilled water minute 80% ethyl alcohol 78

81 minutes eosin-phloxine solution minutes 95% ethyl alcohol minutes 95% ethyl alcohol minutes 100% ethyl alcohol minutes 100% ethyl alcohol minutes xylene minutes xylene Coverslip with mounting media 79

82 8. Calculations Not applicable 80

83 9. Reading and Reporting Results 9.1 READING RESULTS Gross Size, color and shape will be recorded as part of the report. In addition, a description of the gross sectioning will be recorded. Diagrams may be used for clarity. Any unusual aspects of receipt of the specimen should be noted. Example: broken specimen bottle Microscopic A detailed description of the microscopic features may be recorded as part of the report. The results of control tissue for the special stains should be recorded when appropriate Diagnosis A final microscopic diagnosis should be recorded. 81

84 9.2 REPORTABLE RANGE All specimens require a report 9.3 REFERENCE RANGE Not applicable 82

85 9.4 CRITICAL VALUE REPORTING Not applicable 9.5 PROCEDURES FOR PANIC VALUE Not applicable 83

86 9.6 REPORTING RESULTS The final written report should contain the following information: Patient name Unique number or demographic information pertaining to patient Physician obtaining specimen Clinical information Anatomic site Clinical diagnosis or reason for test Microscopic diagnosis Physician making microscopic diagnosis Date of final report 84

87 9.6.2 The following should be appended to the report as part of the permanent record: Consultation reports Results of subsequent tests on the tissue Distribution of reports Patient clinical record Laboratory file Retention of reports The laboratory reports will be maintained for 10 years or in compliance with local and state law. 85

88 10. Procedure Notes Not applicable 86

89 11. Limitations of Procedure The final microscopic diagnosis is highly dependent upon the submitted tissue specimen. 87

90 12 Remedial Actions All out-of-control situations not resolved by a simple repeat analysis will be reviewed by the Laboratory Director as soon as practical after the event. The Laboratory Director will review the corrective action to assure that appropriate action was taken and proper procedures were followed. A Corrective Action Form will be filled out whenever a problem arises in calibration or an out-of-control situation is not resolved by simple repeat analysis. 88

91 12. Sources Farmer, E.R., Hood, A.F. (eds.): Pathology of the Skin. Appleton and Lange, Norwalk, 1990 Prophet, E.B., Mills, B., Arrington, J.B., Sobin, L.G. (eds.): Laboratory Methods in Histotechnology. American Registry of Pathology, College of American Pathologists 89

92 Job Descriptions for Laboratories Performing Tests of High Complexity LABORATORY DIRECTOR The Laboratory Director is responsible for the overall operation and functioning of the laboratory. The following represent the duties of a Laboratory Director: 1. Ensure that testing systems developed and used for each of the tests performed in the laboratory provide quality laboratory services for all aspects of test performance. 2. Ensure that the physical plant and environmental conditions of the laboratory are appropriate for the testing performed and provide a safe environment in which employees are protected from physical, chemical and biological hazards. 3. Ensure that test methodologies selected are capable of providing the quality of results required for patient care. 4. Ensure that the laboratory is enrolled in a HCFA-approved proficiency testing program. 5. Ensure that quality control and quality assurance programs are established and maintained to assure the quality of the laboratory services provided and to identify failures in quality as they occur. 6. Ensure the establishment and maintenance of acceptable levels of analytical performance of each test system. 7. Ensure that all necessary remedial actions are taken and documented whenever significant deviations from the laboratory s established performance specifications are identified, and that patient test results are reported only when the system is functioning properly. 8. Ensure that reports of test results include pertinent information required for interpretation. 9. Ensure that consultation is available to the laboratory s clients on matters relating to the quality of the test results reported and their interpretation concerning specific patient conditions. 10. Employ a sufficient number of laboratory personnel with the appropriate education and experience or training required to provide appropriate consultation. 90

93 11. Ensure that, prior to testing patients specimens, all personnel have the appropriate education and experience, receive the appropriate training for the type and complexity of the services offered, and have demonstrated that they can perform all testing operations reliably to provide and report accurate results. 12. Ensure that policies and procedures are established for monitoring individuals who conduct preanalytical, analytical and postanalytical phases of testing to assure that they are competent and maintain their competency to process specimens, perform test procedures and report test results promptly and proficiently. Also, whenever necessary, identify the need for remedial training or continuing education to improve skills. 13. Ensure that an approved procedure manual is available to all personnel responsible for any aspect of the testing process. 14. Specify, in writing, the responsibilities and duties of each consultant and each person engaged in the performance of the preanalytic, analytic and postanalytic phases of testing, identifying which examinations and procedures each individual is authorized to perform. Indicate below (Yes or No) whether the Laboratory Director will perform this function. Yes No 91

94 Job Descriptions for Laboratories Performing Tests of High Complexity GENERAL SUPERVISOR The General Supervisor is responsible for the day-to-day supervision of the laboratory operation. The following represent the duties of a General Supervisor: 1. Responsible for providing day-to-day supervision of high complexity test performance by testing personnel. 2. Must be on site to provide direct supervision when high complexity testing is performed. 3. Responsible for monitoring test analyses and specimen examinations to ensure that acceptable levels of analytic performance are maintained. 4. Responsible for the annual evaluation and documentation of all laboratory personnel. Indicate below (Yes or No) whether the Laboratory Director will perform this function. Yes No 92

95 Job Description for Laboratories Performing Tests of High Complexity TESTING PERSONNEL The Testing Personnel are responsible for specimen processing, test performance and for reporting test results. The following represent the duties of Testing Personnel: 1. Follow the laboratory s procedures for specimen handling and processing, test analyses, and reporting and maintaining records of patient test results. 2. Maintain records demonstrating that proficiency testing samples are tested in the same manner as patient samples. 3. Adhere to the laboratory s quality control policies. Also, document all quality control activities, instrument and procedural calibrations, and maintenance performed. 4. Follow the laboratory s established corrective action policies and procedures. 5. Be capable of identifying problems that may adversely affect test performance or reporting of test results. Also, must be able to either correct the problem or immediately notify appropriate personnel. 6. Document all corrective actions taken when test systems deviate from the laboratory s established performance specifications. Indicate below (Yes or No) whether the Laboratory Director will perform this function. Yes No 93

96 Job Descriptions for Laboratories Performing Tests of High Complexity TECHNICAL CONSULTANT The Technical Consultant is responsible for the technical and scientific oversight of the laboratory. The following represent the duties of the Technical Consultant: 1. Select test methodology appropriate for the clinical use of the test results. 2. Verify test procedures performed and establish laboratory s test performance characteristics, including the precision and accuracy of each test and test system. 3. Enroll and participate in a HCFA-approved proficiency testing program. 4. Establish a quality control program acceptable for the testing performed in the laboratory. 5. Resolve technical problems and ensure that remedial actions are taken whenever test systems deviate from the laboratory s established specifications. 6. Ensure that patient test results are not reported until corrective action has been taken and the test system is functioning properly. 7. Evaluate the competency of all Testing Personnel and assure that staff members maintain their competency to perform test procedures and report test results promptly and accurately. 8. Evaluate and document the performance of individuals responsible for high complexity testing at least semiannually during the first year the individual tests patient specimens. Thereafter, evaluations must be performed at least annually. Indicate below (Yes or No) whether the Laboratory Director will perform this function. Yes No 94

97 Job Descriptions for Laboratories Performing Tests of High Complexity CLINICAL CONSULTANT The Clinical Consultant provides consultation regarding the appropriateness of the testing ordered and interpretation of the test results. The following represent the duties of the clinical Consultant: 1. Assist the laboratory s clients in ensuring that appropriate tests are ordered to meet the clinical expectations. 2. Ensure that reports of test results include pertinent information required for specific patient interpretation. 3. Ensure that consultation is available and communicated to the laboratory s clients on matters related to the quality of the test results reported and their interpretation concerning specific patient conditions. 95