PHILIPPINE SOCIETY OF PATHOLOGISTS, INC.

COMMITTEE ON ACCREDITATION AND RESIDENCY TRAINING

NAME OF INSTITUTION:

ADDRESS

CHAIRMAN

CRITERIA
Compl Major Notes for Accreditors
iant? Criteri
(Please note that an accreditation visit will not be done until all your (Yes a?
documents have been submitted) or No)

A. General Requirements
### DOH License to Operate Y
a. Tertiary Laboratory Y
b. Hospital-based laboratory Y
c. Licensed Sections:
i. Hematology Y
ii. Clinical Microscopy Y
iii. Serology and Immunology Y
iv. Mircobiology Y
v. Clinical Chemistry Y
vi. Blood bank with additional functions; In regions with a centralized Y
blood bank, the residents must have a rotation there.
vii. Anatomic Pathology Y

B. Staffing Requirments
### There should be at least 3 pathologists, all board certified. Y
a. The chair should be a fellow of the PSP in CP and/or AP. Y If you are not sure if the Chair is a fellow, ask Divine
as she has a list. The Fellow certificate is also
expected to be submitted with the other application
documents.

b. The training officers should be: Y

 i. AP or AP-CP for Anatomic Pathology training Y
ii. CP or AP-CP for Clinical Pathology training N
iii. There can be 1 training officer for both AP and CP Pathology N
training program
iv. The training officer should have undergone the PSP workshop for Y
training officers. (For future implementation)
### For AP, ratio must be at least 1 AP consultant for every 3 residents. Y
### For CP, ratio must be at least 1 CP consultant for every 3 residents Y

N Documents: Logbooks of referrals in CP,

Consultant supervision on site must be evidenced by Record of regular conferences, surgical reports/logbooks,
### Consultant-Resident interaction (like referrals, conferences, lectures) for referral logbooks for AP/proof of referral
Consultants who are part of the Training Program as: c.1. lecturer c.2.
attendee
### All consultant staff who are part of the Training Program (including Y
visiting consultants) must show proof of continuing medical education -
at least 15 CPD units of pathology seminars/workshops/conventions in a
year as an attendee.
### All sections/units involved in Pathology training should be headed by a Y One way of verifying this is by checking
pathologist certified in the corresponding specialty (AP/CP). the result forms (current) or you can also
backtrack/ organizational chart and
admin appointment.

C. Training Program
### A structured training program is in place. Documentary evidence Y
includes, but not limited to the following:
Y
a. Institutional policy for recruitment, appointment, eligibility, and
selection
Scheduleofofresidents
conferences* (intradepartmental, interdepartmental and
b. interhospital), journal clubs, seminars, etc. with corresponding Y
attendance logbook
i. There should be at least 2 AP and 2 CP intradepartmental Y yes, weekly.
conferences** every month.

*A conference is defined as an official activity wherein all residents are in

attendance with at least 2 consultants present.
Sample types of conferences:
**Intradepartmental: Journal club, difficult/ interesting cases conference, autopsy conference,
surgical audits, lecture series (AP conference hour, CP conference hour), etc.
Interdepartmental: tumor boards, grand rounds, Clinico-pathologic conference, pre-operative
conference, multidisciplinary meetings, conferences with other departments, etc.
Interhospital: Metrowide Consortium for the Advancement of Pathology (MCAP), conventions,
round table discussions, etc.

c. Schedule of rotations in both AP and CP for all residents, including Y

outside rotations

i. There should be a total of 6 months rotation in both AP and CP Y You can verify this by:
per year. (Recommendation: maximum of 3 continuous months - Schedule of rotation
rotation per discipline) - questions re the routine
process in the section
- frequency of qc running, howmany
levels, how to troubleshoot
d. Evaluation schemes: performance evaluation (annual) and Y In-service exam result
written/practical examinations (For inclusion in the PSP workshop for
training officers)
### Training program manual based on current Training Program in AP & CP Y Current is still the one released in
is reviewed, signed and dated by consultants 2013, the Competency based TP.

a. Training program must have been read by the residents and signed in Y Check the 'conforme sign'.
conforme upon admission into the program

D. Anatomic Pathology
### The following services must be available:
a. Surgical Pathology Y
b. Cytology (including imaging guided biopsies) Y
c. Frozen Section Y Cryostat/separate FS logbook - 1 year
if cryostat not working at time of visit
d. Autopsy Y table, water supply, saw
There must be a hospital policy mandating submission of all inpatient Y Look for the document.
###
surgical AND cytology specimens to the laboratory.
### Results, surgical and cytopathology slides, blocks, and photographs (if N
available) are filed for easy retrieval and for research purposes
### The following minimum volume of work is required:
a. Surgical pathology - 600 specimens (in-house)/resident/year Y
 *Rotators must be taken into account and included in the computation. List of rotators with MOA/Proof of outside
rotation countersigned by consultant in
other constitution
i. Variety of cases (to follow later) Include in next revision.
b. Cytology (gynecologic and non-gynecologic) - 300 specimens/resident/year (to Y
c. Frozen section - 10 cases/resident/year Y
d. Autopsy - 10 cases/resident/4 years or training period (for residents N 5 cases/resident/4 year training
who started end of 2016 & earlier) period for residents who started
2017; as required by the BOP.

*Partial autopsies should include minimum of thoraco-abdominal organs.

e. Immunohistochemical studies - 25 cases/resident/year Y Should be read in-house --IHC
Logbook
i. Cases — not stains — are counted.
ii. Variety is encouraged.
iii. Increase in number of cases is applicable for new applicants for
accreditation starting July 2018
f. Molecular pathology rotation (optional) N Encourage all institutions to open
MolPath rotations
Proposed seminar/workshop on Molecular Pathology by PSP.
### Rotations with another institution to supplement deficiencies in item 4 Y
above should be covered by a Memorandum of Agreement or a
certification.
### The following equipment must be present in working condition:
a.Microscopes (Minimum ratio should be 1 microscope for every 2 residents) Y
b.Double or multi-header Y
c. Microtome Y
d.H&E and papanicolau stains Y
e.Morgue with autopsy facility Y
f. Cryostat Y
g.Well-ventilated cutting room with at least 1 exhaust fan Y

E. Clinical Pathology
### The lab must have the following capabilities (this lists the minimum
requirements necessary; no MOA with another laboratory will be accepted
unless to supplement the minimum number required; the equipment must be
in working condition, i.e., if machine is not working for more than 3 months in a
year, this will be considered as if the tests are not being offered)

a. Hematology with back up plan for all sections.

i. Automated hematology analyzer (5-part) with back-up machine Y
 ii. Peripheral blood smear Y
iii. Coagulation Testing Y
iv. Malarial smear Y
v. ESR Y
b. Clinical Microscopy
i. Urinalysis Y
ii. Fecalysis Y
iii. Semenalysis Y
iv. Other body fluids examination Y CSF Pleural Peritoneal ; see logbook.

c. Serology and Immunology

i. Hepatitis profile (minimum: HbsAg, anti-HBs, Hbe, anti-Hbe and anti-Hbc Y
II. HIV testing Y
iii. Thyroid function tests (minimum: TSH, T3 and T4) Y Should be under laboratory
supervision and rersidents must be
iv. Pregnancy test rotating in the section, supervised by
v. Tumor markers, note down test available Y a
AtPathologist.
least 1 tumor marker
d. Microbiology
i. Biosafety Cabinet Y
ii. Gram Stain Y
iii. KOH Y
iv. AFB smear Y
v. Culture and sensivitiy Y Gram (+) and Gram (-) organisms;
check results logbook or LIS
e. Clinical Chemistry
i. Lipid profile (cholesterol, triglyceride HDL and VDL) Y
ii. BUN and creatinine Y
iii. Glucose AND Hba1c Y
iv. Liver function tests (minimum: SGOT, SGPT and TB/IB/DB ) Y
v. Electrolytes (minimum: sodium and potassium) Y
vi. Total protein, albumin and globulin Y
vii. Cardiac markers (minimum: troponin) Y
viii. POCT policy and supervision Y administered & operated by the lab

f. Blood Bank
i. Blood typing Y
ii. Crossmatching Y tube method
iii. Serological screening (Hepatitis B & C, HIV, malaria and syphilis) Y ELISA for HIV testing
 iv. Equipment for processing Y
1) Refrigerated centrifuge Y
2) Plasma freezer Y
3) Blood bank refrigerator Y
4) Plasma thawer Y
5) Platelet agitator Y
6) Plasma extractor Y
7) Tube sealer Y
v. Donor screening and bleeding Y
g. Drug testing lab (or rotation outside in an institution with an N This should be included in the
accredited training program with proper documentation) residents' rotation. There should be a
LTO or a MOA with an outside DT lab.
h. Water testing lab (optional) N Check if senior resident has rotated in
### There must be a minimum of 20,000 tests in CP per resident per year. Y
### In institutions with no designated physician to screen donors, a hospital policy Y
and duty roster should be in place, reflecting sharing of donor screening
responsibilities with all clinical departments with no prejudice towards
pathology residents. Duty as donor screener should not exceed more than 7
days per Blood Bank rotation per year.

F. Other requirements:
### N Check portfoilio and note in what
Research schedule (including case reports) and/or timeline of research
stage the research is already.
activities.
### Y - referral of MT to resident to H147;
Referral logbook in CP to include, but not limited to, the following data: documented; proof that consultant
Patient's name/age/sex/brief description of problem or issue/action checks the referrals regularly or
taken/ resident in charge/referring staff periodically.
- Hema, BB, blood transfusioon
reactions, panic values, lab
G. Resident's portfolio (presented upon inspection)
management, troubleshooting
1 Updated curriculum vitae
2 Certificate/s of attendance in pathology convention/scientific meeting (at least 1 per year).
3
Comprehensive examinations/test papers: at least 1 theoretical exam each in AP
and CP per year AND at least 1 practical exam each in AP and CP per year.
4 RISE results
5 Copy of case report (at least 1 case either in AP or CP)
6 Copy of research paper (1 in AP and 1 in CP)
H. Reference Materials:
licensed; original
The following are the minimum books required to be in the laboratory's
library whether in hard copy. The book should be the latest edition or not
more than 4 years from the date of publication:
Copy of pertinent DOH administrative orders and other issuances Y
1 Robbins Y
2 Rosai and Ackerman's Surgical Pathology Y
3 AJCC/ CAP Cancer Staging Manual Y
4 Clinical Diagnosis and Management by Laboratory Methods by Henry Y
Water testing manual N
Tietz Clin Chemistry N
5 AABB Technical Manual Y
6 DOH Blood Bank standards Y
7 Any reference for cytopathology N
Drug testing manual Y
8 Any reference for autopsy pathology N
9 Internet access Y
I. External Evaluation
Results of the annual In-service examinations showing participation of ALL Y
I residents. If absent, a duplicate copy of the excuse letter signed by the
training officer and submitted to the CART, must be presented. Residents
who started their training less than 90 days from the exam date are
excused from taking the exam/OPTIONAL.

2 N
Training Officers must encourage the graduates of the program to take
and pass the board examination within 4 years upon graduation. Written
pledge must be signed and undertaken by the resident as explained by
the training officer. (Will be part of the Training Officers workshop)
75% of graduates of the program must have taken the board N To be discussed again; for revision ---
examinations within 3 calendar years after graduation. further clarification in next version of
3 checklist.
At least 25% of the graduates of the program must have taken and N If
Todid
be not take 3 years
discussed again;after
for revision ---
passed the board examinations within the past four years. graduation, may recommend one of
further clarification in next version
year refresher.
checklist.
4
*The institution must fulfill ALL major criteria to get a 3 year accreditation.
One major or 3 minor (i.e. not in the list) deficiencies are given one year
probationary period.
For outside rotations, an option would
be to visit the site of 'outside rotation'
This checklist will have its soft run this accreditation year and is expected to
if you think there is a need to
be revised/fully applicable by accreditation year of 2019.
validate.

CAPTP July 13, 2019