5 Tips For Surviving A CAP Inspection - Updated

By Kristen Holshoe, BS, MLS (ASCP)

March 26, 2021

StaffReady is re-releasing this blog article, originally published in 2018.  It has great content, and some additional information and links have been added.  We hope you find this useful! - Editor

I recently went through a CAP inspection for our lab. In fact, it was my sixth time having gone through an inspection. And even after this much experience, my nerves were on edge awaiting the inspector’s arrival.

Prior to an inspection, lists of to-do items run through my head as the date draws near. “Did I get all my direct observations signed?” “Did I document the 6-month competency for my new hires?” “Are my temperature logs up to date?”

The tasks seem endless.

Here are 5 areas that I focus on to help me get organized and feel confident for a CAP inspection. I hope they are helpful for you as well.

Know Your Checklists

One of the most important steps in preparing for a CAP inspection is to make sure you are using the correct version of the CAP checklists. Based on the timing of your inspection, a specific version has been assigned as the one inspectors will evaluate you on. Make sure that you read the requirements in their entirety, as some very critical points are often listed in the “notes” section. The best way to determine whether you are meeting a requirement is to read through the “Evidence of Compliance” section. It isn’t uncommon to read through a requirement and think, “Oh yeah, I’m doing that. No problem.” and then get to the “Evidence of Compliance” section to find out you not only need to be doing it, but you also need to have a procedure specific to that task. Resist the urge to skim. (Editor’s note – we also covered documenting this evidence in our 10/02/2020 blog article.)

Revisit the Past

Take the time to revisit your department’s prior CAP deficiencies as well as your previous year’s self-inspection. It’s almost a guarantee that some level of attention will be focused here as CAP will want to verify prior deficiencies have been corrected and that those corrections are being maintained over time. One thing you may want to try is to create a small binder of examples for the inspector to use as a reference for your current processes. This could include things such as examples of the most recent instrument calibrations, method or instrument correlations, alternative proficiencies, and competency performance. (Editor’s note – Dr. Elzie covered this recently here and here.)

Organize Stuff and Staff

In order to feel confident on the day of inspection, you will want to work on getting as organized as possible. Make sure all your procedure, validation, and implementation manuals are in the same place or, at the very least, easily retrievable. Evaluate your procedures and confirm they have all been appropriately reviewed and signed within the past two years. Sort through reagent, maintenance, and communication logs and keep the most current information easily accessible. Perform multiple departmental walk-throughs and audit for date, time, and initials on any open reagents and QC. This is also a great time to scan around for any expired stock in the process (consumable items can be very easy to miss). Make it a point to remind your staff of their important role in the upcoming inspection and what they may expect - especially for any lab scientists that are new to the profession. You may even consider asking them to take an active role by enlisting their help with going through the requirements with you. Not all lab scientists have worked with a CAP checklist before. When made aware for the first time, many are stunned to discover what is actually required to keep a department afloat. (Editor’s note – these concepts was addressed in November and December 2020 in a four-part series on Joint Commission Surveys. The agencies differ, but the concepts are the same.)

Remain Calm

Let’s be honest, regardless of how prepared you are, a CAP inspection can be incredibly intimidating. The best thing you can do is remain calm, exude confidence, and greet them with a smile. Make sure you take the time to briefly tour them around your lab and introduce them to your staff. The rest of your day is going to feel quite honestly, chaotic. Procedure manuals are sprawled open everywhere, staff are hyper-vigilant and you’re playing “gopher” producing endless examples of specifically-requested documentation. Of course, in the meantime, the lab is still in operation and depends on you as their leader. Mentally prepare yourself ahead of time that this will be a day that tests your endurance and your ability to lead in times of stress. (Editor’s note – there are some gems in this article. Set your lab up for success!)

Be Present and Accountable

During inspection day, it is important to be present for the inspector and cooperate with their requests for information as efficiently as possible. Make sure they have everything they need to make an informed assessment of your performance. During discussions, answer honestly and accept constructive criticism professionally. When deficiencies are found (which is quite common), make sure you “own up” to any oversights on your part. If challenging a potential citation, backing up any explanations with documented proof will go a long way toward proving your compliance.

In the end, CAP inspections are necessary to safeguard our intent to provide safe, quality patient care. Knowing some tips ahead of time will allow you to be as prepared as possible. Now, get on those deficiency response forms – you’ve only got thirty days!

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Photo credit: Pat Olson, Tyler Olson

Kristen Holshoe, BS, MLS (ASCP)

Kristen Holshoe is the Hematology/Coagulation laboratory supervisor at a northwest Michigan hospital. As is evident in her quality of work, she is proud to be a valuable part of the healthcare team performing complex testing as a Clinical Laboratory Scientist.

With 15 years of experience in the field, Kristen is passionate about promoting her profession through education and networking in an effort to make the career more “visible” Find Kristen on LinkedIn.