College of American Pathologists
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cap today

September 2005
PAP/NGC Programs Review

Ed Finkel

Lab inpections, just a few key strokes away
"What’s New" within the Laboratory Accreditation Program
CAP resources

Lab inpections, just a few key strokes away

For those preparing to inspect a lab or to have their own lab inspected, accreditation program resources are plentiful—and just a few keystrokes away.

These resources, posted on the CAP’s Web site (, consist of a complete set of checklists, information change forms, deficiency response forms, the accreditation manual and standards, virtual audioconferences, proficiency testing documents, and an inspector training eLearning course.

These materials aren’t new, but they have escaped the notice of some laboratorians, says Pauline Jurney, technical specialist for proficiency testing with the College’s accreditation program. "What we’re finding is that even people who use our services don’t know there’s a Web site out there with all this information on it," she says. "We’re hoping that if they know about our Web site, they’ll be able to access the information easily."

Though it’s easy to access now, and most of it is available on CD-ROM as part of the application and inspection materials, the resources will be even more user-friendly by year-end. That’s when the CAP will launch its redesigned Web site with an entirely different, more streamlined navigation structure, says Juliane Trapp Pearson, the CAP’s team leader for Web design and content management. "We’re undertaking the project in response to customer and member feedback," she says. "It’s much more focused on what people are coming to the site to do and making sure they get the information they need."

During the average business day, about 10 inspections staffed by 80 volunteers take place throughout the country. "We are always trying to make sure that people who are going out to inspect are trained," Jurney says. "Getting people to volunteer their time is not easy. The easier we can make the whole process—application, getting ready, going out on inspection—the better."

"What’s New" within the Laboratory Accreditation Program

Leading off the laboratory accreditation portion of the site now is a "What’s New" section that brings members up to date on the latest news within the Laboratory Accreditation Program, says Francis E. Sharkey, MD, the CAP accreditation program commissioner for education and a pathologist at the University of Texas Health Science Center, San Antonio. "This is a nice place to identify changes to lab accreditation programs. As changes develop, they very quickly get posted," he says. "It’s a quick way to communicate with people without necessarily having to send an e-mail to everybody in the program."

A section titled "About CAP Laboratory Accreditation Programs" describes how to become a CAP-accredited laboratory, why you should want your lab to be accredited, and whom to contact, Dr. Sharkey says. This includes several forms, such as the application request form, which can be completed on the computer.

A section about CAP system inspections provides information on the features of inspections of affiliated laboratories, such as how to qualify, how to get started, and what training options are available. "They [the labs in the system] all get inspected by the same team at about the same time, and then once every two years they go out and inspect a group of laboratories of similar size and scope," Dr. Sharkey says. "Systems laboratories have a number of different features and qualifications that are addressed in this area."

The Web site includes complete and current checklists for all sections of the laboratory downloadable in Word and PDF formats. Checklists on the Web site include explanatory commentary and references-information not in the printed checklists. Those who use the electronic checklists can employ Microsoft Word’s edit/find feature to search quickly by checklist number or topic, such as specimen collection. Also on the Web site are Word documents listing the most recent changes in each checklist.

Laboratories are inspected with the customized checklist versions that are sent out with the application form. This gives the lab about five months to use the checklists to prepare for inspection. The inspectors are sent the same customized versions.

"It’s very common that there’s a more current checklist version on the Web site," Dr. Sharkey says. "Older checklist versions are also available at the Web site, as is the ’changes’ document that highlights just the changes between one version and another." Labs that want to see only the new or changed requirements should use the "changes" documents.

The checklist page probably gets the most hits on the CAP Web site, Jurney adds, noting that the Word format can be manipulated and customized to the lab’s own way of storing information, which helps reduce paperwork.

Another page, "Information for Laboratories," contains the Standards for Laboratory Accreditation, the Laboratory Accreditation Manual, laboratory change forms, and a master activity menu. The standards document spells out in general terms what a laboratory must accomplish to earn CAP accreditation, Dr. Sharkey says. This covers four areas: the laboratory director’s qualifications, physical facilities and safety, quality control and performance improvement, and inspection requirements.

The Laboratory Accreditation Manual is the most comprehensive resource for accreditation. "It’s the program ’bible’ and includes the A to Z of the inspection cycle, how to inspect, and how to prepare for inspection," says Mary Groff, the CAP’s education specialist for accreditation programs.

The remaining forms and reports are simply ones members often call and ask about. "We put them out there so they can have quick, easy access," Jurney says.

The change forms are required any time the laboratory makes a significant change of any sort. Among the key change forms posted is a test menu form used when "the lab adds or deletes testing capabilities," says Dr. Sharkey, who adds that another important change is ownership. "Accreditation does not necessarily survive if there is a change of ownership," he says.

The master activity menu describes what analytes a laboratory tests and by what methods. "This tells CAP what the laboratory should be doing proficiency testing for," he says.

The deficiency response forms are completed by the lab after its inspection, Jurney says, and the lab must respond in writing to explain how it corrected the deficiencies the inspection team noted. "The nice thing about the forms here, as well as on the CD, is that they can be completed on the lab’s PC," she says, adding, "They can’t submit their responses to us electronically—yet."

Another page, "Information for Inspectors," includes such resources as "20 steps to a CAP inspection for team leaders" and check-off lists for team leaders consisting of a to-do list from pre- to post-inspection. A team member check-off list is also available.

"CAP provides a lot of education for people who are going out to inspect," Dr. Sharkey says.

CAP resources

Among the resources the CAP provides are daylong inspector training seminars and half-day seminars for specialty groups, as well as audioconferences that cover a pathology subspecialty or "more general topics like how to get the information when you’re inspecting," Dr. Sharkey says. "We’re trying to ensure that the inspectors are prepared to do a consistent, efficient, and thorough job," he says.

The CAP funds its training through accreditation fees, so the 15 to 20 live seminars each year are free to accredited laboratories, Groff says. "At the daylong seminar we spend the entire morning demonstrating how to inspect. Most people are already subject-matter experts. We’re trying to concentrate instead on the actual mechanics of inspecting." Groff says the mechanics include "how to ask questions, how far to drill down into the records, how to be efficient, how to be thorough."

The audioconferences are offered each month and presented live, then put into a virtual library. Individuals can download the handouts, listen to the audio file, and project the slides. The audioconferences, of which about 35 are posted, are the only Web site offering that’s not on the CD-ROM. Though some date back to 2000, "many remain very valid," Groff says.

The audioconferences are offered live about 10 times a year, have about 2,500 to 3,000 attendees each, and usually last one hour, with 45 minutes of presentation and 15 minutes of questions and answers. Attendees can submit questions via e-mail for up to two weeks afterward, and the CAP compiles a document, which includes all the questions and answers, that’s posted on the Web with the audio files about three weeks later. "They’re just sitting out there waiting to be accessed, and they’re wonderful," Groff says.

The proficiency testing folder contains information on enrollment requirements and frequently asked questions that tie into the accreditation checklist questions, says Mari Gina Phillips, CAP technical specialist for proficiency testing. A companion Proficiency Testing Exception Summary, or PTES, report gives accreditation participants criteria for monitoring proficiency testing scores. "This report describes the acceptable thresholds for the PT monitoring process," she says.

Phillips adds: "We also include a document that outlines the items, specifics, to providing a complete and thorough response to the PTES report. A laboratory should use these specifics to investigate every unacceptable PT response the laboratory has produced."

Ed Finkel is a writer in Evanston, Ill.