Preparing for a CAP Inspection - Part 2

By Darryl Elzie, PsyD, MHA, MT (ASCP), CQA (ASQ)

February 19, 2021

In Part I of this series, we talked about preparations a laboratory could make in getting ready for an initial or biennial CAP inspection. Part 2 will focus on preparing staff for a CAP inspection.

Staff preparation

Laboratory staff are integral to successful laboratory operations. The CAP recognizes this fact and tasks inspectors to ask staff questions to ensure they are aware of the policies and procedures forming the framework of laboratory operations.

Lab directors and managers should ensure staff are ready for inspectors' questions regarding quality control, policies, and procedures (especially those involving critical values), and how they are involved in quality management. Some examples of questions asked: What happens when an unacceptable specimen is received? What identifiers are used to identify a sample?

It would be worthwhile to have staff review policies and procedures to make sure they are comfortable recalling information.

Tracking a Sample

Similar to other accrediting organizations, CAP inspectors may track a sample from collection to result verification to ensure personnel are following the laboratory's policies and procedures. Some staff may find this an intimidating and stress-inducing ordeal. Reassuring staff and reminding them they successfully perform these tasks daily will help remove some stress from having an inspector following and observing them while performing their job.

Senior or lead techs are often heavily involved in answering questions from inspectors. They should be prepared to provide information on the proficiency testing process and quality control. Prior to the inspection, a review of all quality control and manual logs from the previous two years should be completed to ensure there are explanations or corrective actions for any out of control results or blank logs.

Wear PPE

Some may think it doesn't need to be said, but lab managers and senior personnel should be diligent and remind all staff to make sure they are wearing the appropriate personal protective equipment (PPE) during the inspection. Staff not wearing PPE is one of the low-hanging deficiencies (mentioned in Part 1) that inspectors would quickly write up.

It is essential to remind staff that the administration is very confident in their abilities and should just do what they always do to provide high-quality lab results. Let them know the bulk of a CAP inspection team is made up of their colleagues from other similar hospitals or independent labs doing the same type of work.

Virtual Inspections

It should be mentioned that the COVID-19 pandemic has introduced some new and additional challenges to the laboratory inspection experience. The CAP has temporarily initiated virtual inspections across the nation to meet its accrediting obligations.

The laboratory director and the inspection team must both agree to a virtual inspection. Some requirements need to be met for a successful virtual inspection for laboratories in states under travel restrictions requiring visitors to quarantine or have visitation restrictions put in place by their institution.

To reduce headaches and hiccups during a virtual inspection, laboratories need to make sure they have robust and reliable Wi-Fi, laptops, tablets, or phones with a microphone and camera. (The lab will need to request their IT department to install some type of meeting software like Skype, Zoom, Microsoft Teams, etc.). Provide suggestions to staff to help them become comfortable interacting with inspectors virtually.

Electronic Document Control

If a laboratory is still using paper manuals, it would be a great time for presenting a proposal to the administration to invest in an electronic document control system. In a virtual inspection, laboratories using paper manuals will need to scan and upload relevant policies and procedures for inspection review. Scanning and uploading is a cumbersome and time-consuming process.

Life is much easier in the laboratory when there is an electronic document control system in place.


Part 1 of the series discussed some of the work needing to be done in preparation for an onsite CAP inspection. Though inspections are unannounced (unless it's an initial inspection), having a call-tree, a large room reserved, and a sizable cart ready are some of the small things that make a difference in smoothing out the inspection process.

Part 2 focused on preparing staff for interacting with inspectors and reminding them of the confidence lab directors and managers have in their abilities. Virtual inspections are now a reality for the present and near future. Preparations need to be made, such as ensuring laptops and phones with cameras and microphones are available.

The well-prepared lab should feel confident, not overwhelmed, on inspection day. Though there will always be some stress accompanying any type of inspection, having the small things ready or reviewed goes a long way toward reducing stress and avoiding deficiencies.

This concludes Part 2 of the two-part series on Preparing for a CAP Inspection. We hope you found this content insightful and helpful.

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Photo Credit: Elnur Amikishiyev

Darryl Elzie, PsyD, MHA, MT (ASCP), CQA (ASQ)

Dr. Darryl Elzie has been an ASCP Medical Technologist for over 30 years and has been performing CAP inspections for 15+ years. He has a Masters of Healthcare Administration from Ashford University, a Doctorate of Psychology from The University of the Rockies, and is a Certified Quality Auditor (ASQ). He is a Laboratory Quality Coordinator for Sentara Healthcare. Sentara Laboratory Services provides services for 12 full-service hospitals, five ambulatory care centers, and a large number of medical group practices. Dr. Elzie provides laboratory quality oversight for four hospitals, one ambulatory care center, and supports laboratory quality initiatives throughout the Sentara Healthcare system.  Find Dr. Elzie on LinkedIn.