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
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.
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?
would be worthwhile to have staff review policies and procedures to
make sure they are comfortable recalling information.
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.
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
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.
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.
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
across the nation to meet its accrediting obligations.
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.
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
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.
is much easier in the laboratory when there is an electronic document
control system in place.
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
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
The well-prepared lab should feel confident, not overwhelmed, on
inspection day. Though there will always be
accompanying any type of inspection, having the small things ready or
reviewed goes a long way toward reducing stress and avoiding
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