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  Frequently Asked Questions About
  Accredited Laboratory Signs

 

Updated March 13, 2012

For additional information, please contact the Laboratory Accreditation Program staff at accred@cap.org

Why does CAP require the sign to be posted?
What are the posting requirements? What if sections of my accredited site are located throughout the institution?
Can we provide a copy of the sign to everyone instead of posting it on a board or wall?
Does the sign have to be posted in patient care areas, such as outpatient phlebotomy sites or waiting rooms? Do other healthcare workers need to have access to this telephone number?
What other initiatives have been implemented?
How does this initiative affect my facility?
How will the CAP use the complaint information?
Will the laboratory director be notified if someone calls with a complaint about his/her site?
What information will you provide the director about the complaint?
What are the possible consequences to the facility? Can the CAP revoke the site’s accreditation?
How will I know when the CAP’s investigation is complete?
What types of complaints will the CAP investigate?
How will the CAP determine if this is a “true” claim or if someone is making false accusations?
Do I have to contact my director before I call the CAP?
Is the phone number accessible at all times?
Who will answer my call at the CAP?
What information do I have to provide when I call? Will my call be kept strictly confidential?
If the information I provide allows my director to deduce who made the call, how will the CAP protect me?
Can I call the CAP accreditation hotline with information about a facility other than the one where I work?
What happens during the investigation process?
Will I receive feedback throughout the process? How soon can I expect feedback?
What action can the CAP take against the facility?
Will the CAP share my complaint with other organizations?

Why does CAP require the sign to be posted?

In the past, a CAP-accredited facility had engaged in serious violations of CAP Accreditation standards. Personnel revealed these violations to external authorities rather than bringing them to the CAP’s attention first. The case prompted a Congressional hearing at which concern was expressed that clinical laboratory personnel were not always aware that they could contact the CAP about serious quality or safety issues not being addressed in a laboratory. The CAP has a vital role in the accreditation process and has therefore committed to Congress that all personnel in CAP-accredited facilities are made aware that they can use the CAP as a resource in these types of situations.
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What are the posting requirements? What if sections of my accredited site are located throughout the institution?

The CAP requests that the sign be posted in a location that is prominent and visible to all accredited site employees. Examples include an employee bulletin board or a general communication center. If your accredited site is located in several different areas, it might be necessary to post multiple signs. You may obtain more signs from the CAP by calling 800-323-4040 (847-832-7000) option 1 #.
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Can we provide a copy of the sign to everyone instead of posting it on a board or wall?

If you wish to distribute a copy of the sign to all employees as part of this procedure, it should be in addition to the posting. The CAP encourages you to discuss this requirement, as well as your general process for handling quality issues or concerns, with your employees. A Checklist requirement compels all laboratories to have a procedure in place that helps employees communicate concerns about test quality and employee safety.
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Does the sign have to be posted in patient care areas, such as outpatient phlebotomy sites or waiting rooms? Do other healthcare workers need to have access to this telephone number?

The intent is to make the telephone number available only to accredited site employees. However, the CAP does investigate complaints from other sources, including patients and other healthcare workers. Please note that the CAP Laboratory General Checklist quality management questions encourage you to obtain feedback from patients and healthcare providers on a periodic basis.
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What other initiatives have been implemented?

To help ensure that this requirement is implemented appropriately in all CAP-accredited sites, CAP revised accreditation requirements in the Laboratory General Checklist. These requirements deal with procedures and awareness campaigns that help employees appropriately communicate concerns about test quality and employee safety to management. Additionally, directors are asked to identify during the reapplication process any investigations that have been performed at their facility.
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How does this initiative affect my facility?

Most facilities routinely involve their employees in the quality management process, and address any quality concerns promptly and efficiently. Other than posting the sign, most laboratories should not be affected.
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How will the CAP use the complaint information?

The goal of the CAP Accreditation Program is to improve the quality of testing and specimen handling. This initiative will not only allow the CAP to assist individual facilities in their Quality Improvement (QI) endeavors but will initiate improvements in the inspection process. The CAP can then proactively identify quality-related issues in all of its accredited facilities.
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Will the laboratory director be notified if someone calls with a complaint about his/her site?

It is the CAP’s intent to work collaboratively with the director to address any quality concerns. When the CAP receives a complaint, the director will be notified and will be involved in the resolution process. The CAP will keep the identity of the complainant strictly confidential.
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What information will you provide the director about the complaint?

The CAP will share with the director the nature of the complaint and any necessary and relevant details that are provided. The identity of the complainant will be kept confidential.
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What are the possible consequences to the facility? Can the CAP revoke the site’s accreditation?

During a complaint investigation, the CAP will work with the director and staff to resolve the issue(s). The investigation process is similar to responding to deficiencies after an inspection, but may include announced or unannounced inspections to confirm implementation. In extreme cases where serious issues that affect patient care and/or employee safety are not being adequately addressed, the CAP may place the facility on probation, suspend all or portions of the facility, or revoke accreditation.
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How will I know when the CAP’s investigation is complete?

At the conclusion of the complaint investigation, the CAP will send the director, as well as the complainant, a letter informing them of the outcome.
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What types of complaints will the CAP investigate?

The CAP will only investigate complaints associated with its Accreditation Standards and/or Checklist requirements. The CAP does not investigate complaints such as billing fraud, fee-for-service issues, employee hiring practices, and/or result interpretation as it relates to the general practice of medicine.
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How will the CAP determine if this is a “true” claim or if someone is making false accusations?

The CAP takes every claim or complaint seriously and will investigate appropriately to determine if it is substantiated or if any corrective action is necessary.
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Do I have to contact my director before I call the CAP?

The CAP strongly encourages you to work with your director to resolve any quality concerns or issues. If you are unable to do so, or if the internal process does not result in a satisfactory outcome, you may contact the CAP.
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Is the phone number accessible at all times?

The phone is staffed during routine business hours (8 a.m. – 5 p.m. CT). During non-business hours, you may leave a recorded message and we will return your call no later than the next business day.
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Who will answer my call at the CAP?

Senior-level CAP staff members handle all calls. They have technical backgrounds and can appropriately discuss concerns.
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What information do I have to provide when I call? Will my call be kept strictly confidential?

Generally, the more information you can provide the better. You are not obligated to provide your name, but if you do, it will be kept confidential. To assist the CAP in the investigation, you should provide the name and address of the facility as well as your concern—including examples and, if possible, documentation and/or direction in how the CAP can investigate your claim. We also recommend that you provide a way for us to contact you for more information. Again, your name and number will be kept strictly confidential.
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If the information I provide allows my director to deduce who made the call, how will the CAP protect me?

The CAP has a strict whistleblower policy. In the unlikely event that your employer threatens or otherwise harasses you, the CAP will take swift action, likely resulting in the revocation of accreditation.
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Can I call the CAP accreditation hotline with information about a facility other than the one where I work?

Yes. As long as you provide the information outlined above, the CAP will investigate your concern.
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What happens during the investigation process?

The CAP first determines if the complaint is within the accreditation scope. If it is outside the scope, the complainant is notified and the complaint investigation is closed. Otherwise, the CAP will contact the director and begin gathering information—both from the complainant and from the facility. The CAP may request the facility to send information or may obtain information via an inspection, which may be announced or unannounced. Once enough information is gathered, the CAP will determine if corrective action is needed. If so, the CAP will require the facility to make appropriate changes and provide supporting documentation, similar to the post-inspection process, to ensure that it is in full compliance with CAP Standards and Checklist requirements. Another inspection may be necessary to confirm this compliance. At the conclusion of the process, both the director and the complainant are notified of the laboratory’s accreditation status.
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Will I receive feedback throughout the process? How soon can I expect feedback?

The CAP may contact you to obtain more information or to clarify an issue. Because of all the steps involved, the complaint investigation process may take several months. At the end of the investigation period, the CAP will contact you.
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What action can the CAP take against the facility?

The goal of the CAP Laboratory Accreditation Program is to improve the quality of testing and specimen handling. The CAP will work with the director and staff to resolve the issues and make improvements. In extreme cases where serious issues that affect patient and/or employee safety are not being adequately addressed, the CAP may place the facility on probation, suspend all or some of its sections, or revoke its accreditation. Please note that the CAP cannot shut down a laboratory or suspend its Medicare or Medicaid payments. These actions are the responsibility of the state Department of Health and/or the Center for Medicare and Medicaid Services.
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Will the CAP share my complaint with other organizations?

As part of its relationship with other regulatory agencies, the CAP may share the content of your complaint with State and/or Federal agencies or with The Joint Commission. The CAP will not disclose your identity to these organizations.
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