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Staff Communications/Review of Revised Policies by Staff


saralm88

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Hello friends!

 

Quick (and maybe simple) question: how long do we have to keep staff communications (memos that I have them read and sign) or revised policies i put out for them to read and sign?  I know there is a standard for approval of revisions and new policies by the medical director but I can't seem to find one about staff review

 

Thanks!

Sara 

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CAP standard COM.10300 "Knowledge of Policies and Procedures" simply states: The laboratory has a defined process and records indicating that all personnel are knowledgeable about the contents of the policies and procedures (including changes) relevant to the scope of their testing activities.

Our "defined process" indicates that we save those records for 2 years.

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1 hour ago, Kelly Guenthner said:

The laboratory has a defined process and records indicating that all personnel are knowledgeable about the contents of the policies and procedures (including changes) relevant to the scope of their testing activities.

The phrase "knowledgeable about the contents" rather says the same as I said.  They don't just need to have read any changes, but know what they mean and how they are involved in the procedure.

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Our document control system assigns SOPs to the appropriate staff members. They sign off in the system indicating that they've read it and that they understand it. That signoff is maintained as long as the SOP is held in the system, so pretty much forever. If there is a competency requirement along with a new or changed policy, then that is documented and stored as long as any other competency and would be included w/ the documentation for that year.

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