- Hold a pre-summation meeting in private with inspection
- Ensure that all Checklists have been completed as
- 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
- 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
- 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
- Leave a photocopy of the ISR with the Medical Director
- Say Thank You!
- 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
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.