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Summation Conference
Do’s and Don’ts

 

Summation Conference Do’s

  • Hold a pre-summation meeting in private with inspection team
  • Ensure that all Checklists have been completed as appropriate
  • Review deficiencies with inspection team
  • Resolve outstanding issues with the team
  • Record the Requirement ID of the deficiency on the Inspector Summation Report (ISR) pink sheets
  • Provide details on the nature of each non-compliant item
  • Ensure that the laboratory leadership is aware of all deficiencies that will be cited
  • Have team members sign and date the pink sheets of the ISR
  • Prepare the team for the Summation Conference
  • Leave adequate time for the Summation Conference
  • Encourage attendance at the Summation Conference by all
  • Highlight the educational and peer review objectives of the Accreditation Program
  • Introduce the inspection team
  • Be open, positive and supportive
  • Present deficiencies in a straightforward manner with concrete information
  • Allow laboratory to find missing documents and correct deficiencies while the team is on-site
  • Encourage constructive dialogue
  • Emphasize the positive
  • Explain the post-inspection process
  • Have the Team Leader and Medical Director sign the ISR
  • Leave a photocopy of the ISR with the Medical Director
  • Say Thank You!

Summation Conference Don'ts

  • Be rushed
  • Debate the appropriateness of Checklist requirements
  • Allow confrontation between the inspection team members and laboratory
  • Surprise the laboratory with "new" deficiencies at the Summation Conference
  • Solicit business
  • Request access to proprietary information
  • Breach a confidence

Summation Conference Format

All deficiencies should have been discussed with appropriate supervisors prior to summation so that nothing is a surprise at the Summation Conference.

  • Start out positively — Thank the staff for their hospitality and for the educational benefits of visiting their laboratory. Acknowledge Administration and other personnel attending the Summation Conference from outside the Laboratory if applicable.
  • Review the 2 phases of deficiencies and how to respond to each. Also point out the Recommendation pages noting that it is not necessary to respond to these.
  • Reinforce that the Laboratory has 30 days to respond to deficiencies from the inspection date and that no further deficiency report will be sent.
  • Allow each member of the inspection team to "sum up" their findings. Each deficiency should have been discussed with the appropriate supervisors prior to the Conference.
  • It is helpful for putting things into perspective to determine before the summation how many total deficiencies there are as an estimated percentage of total checklist requirements. This is true particularly if the facility Administrator is attending the Conference.
  • Allow time for questions. However — do not get into confrontations about specific deficiencies. Remind the inspected laboratory that the final decision on any deficiency is that of the Regional Commissioner. If the laboratory feels a deficiency is not just, they can contest it in their Deficiency Response. Remind them that it is essential that they include adequate documentation to support their claim.
  • Have the Laboratory Director sign the Signature Page of the Inspector's Summation Report, assemble all pages of the Summation Report and have someone make copies of Part B. These copies will remain with the laboratory and the originals will be sent back to the CAP office per the intructions.
  • Finish the conference again on a positive note.
 

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