College of American Pathologists

  Inspection Process Committee


   Posted August 13, 2012


Reports to: Commission on Laboratory Accreditation

Charge: Provides oversight of pre-inspection and inspection processes to improve the timeliness and quality of inspections.

Major Tasks:

  1. Assure Program policies regarding inspection assignments are consistent and objective.
  2. Establish metrics and monitor the timeliness and effectiveness of inspector assignments and inspections.
  3. Establish and monitor a process for conducting validation inspections for which feedback on the effectiveness of assignments, education and other program initiatives could be assessed and serve as input for Program improvement.
  4. Establish algorithms for effective team assignment, which gives consideration to several factors including but not limited to laboratory size and complexity, accreditation status, conflicts of interest, experience of team members, and the laboratory and inspecting team’s laboratory’s projected risk of non-compliance. These factors may result in the assignment of expert inspector(s) (including staff) to supplement or replace an assigned local team.
  5. Oversee Specialty Program assignments (i.e., Inter-Region, Children’s Hospitals, RLAP, FDT, Systems, International).
  6. Provide guidance for the development of inspector tools designed to improve inspection effectiveness and documentation of deficiencies. This function includes establishing standards for pre-inspection review of laboratory information (e.g., Quality Manual), and translation of gathered data into actionable direction for the inspection team.

    Note: The “inspection tools” or Checklist component is specifically the responsibility of the Checklist Committee.
  7. Provide input to the ongoing refinement of the Application/Re-application process and tools including eventual conversion to an Internet-based process.
  8. Monitor the impact of Unannounced Inspections including identification of inspection techniques and inspection preparation tips that improve the inspection and mitigate issues related to inspections being Unannounced.
  9. Develop and oversee Inspector Management programs, including inspector credentialing, mentoring, feedback mechanisms, recognition programs, do not use process, and identification of inspection team rosters prior to inspection, and other Board-approved initiatives assigned to the Committee.

Time Commitment Time Commitment

Number of face-to-face meetings: 3
Length of each meeting: 1 day

Location of meetings(i.e. all airport locations, 50 miles from airports, all DC. Please note if there is a common location of a meeting – i.e. one meeting is always in Chicago or DC): Most meetings will be within 30 minutes of an airport.

Number of conference calls: 1 per Month

Hours of committee work required outside of meetings: (i.e. journal review, liaison activities, writing critiques, email communications): 3 hours per month on average.

Additional travel or time commitments (i.e. leadership meetings, other organization meetings): Attendance by the Chair at CLA and State Commissioner meetings.

Activities of Committee Activities of Committee

  • Oversight and endorsement of materials created for the development of the inspection process i.e.: inspector packet.
  • Define the policies for the program related to inspector assignment and inspection process.
  • Review inspection assignment and on-time inspection statistics
  • Evaluate Do Not Use Inspectors.
  • Review outcomes of validation inspections and performance measures.
  • Review outcomes of the LAP inspection process and make recommendations for improvement as appropriate.
  • Oversight and endorsement of Inspector Management Program and associated policies.

Expertise or Experience Required Expertise or Experience Required

  • Knowledge of inspection preparation through conducting inspections
  • Knowledge of laboratories
  • Some knowledge of accreditation process

Benefits to membership on this committee Benefits to membership on this committee

  • Experienced is gained in the development of inspection process initiatives and implementation.
  • Opportunity to publish materials.
  • Opportunity to speak at education events.

Representation on committee beyond the CAP:

  • Liaison representation on the Council on Accreditation (CoA) as appointed

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