College of American Pathologists
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  Inspection packets made more user-friendly


August 2007
Originally published in CAP TODAY

Ed Finkel

In the past, CAP laboratory inspection team leaders have spent more preparation time than they would have liked toiling in the vein of the famous Rob Schneider character of 1990s “Saturday Night Live” vintage: makin’ copies.

The College sent out a single copy of the inspection packet, “which sounds logical,” says Jack Garon, MD, a participant in a recent CAP focus group and pathologist at Mt. Sinai Hospital, Chicago. “Except that when the inspection team gets it, it’s not going to one person.”

The typical inspection team might consist of a dozen people, and all of them will need certain documents while those inspecting only select areas of the lab will need others, Dr. Garon says. “For example, every team member needs a copy of the previous deficiencies of the area they will inspect,” he says. “There’s this long period of figuring out what to duplicate for each inspector. And these are big documents.” Printing an extra copy or photocopying them were the options. “Neither one is particularly appealing, when you’re talking about hundreds of pages,” he says.

With that in mind, the CAP has rolled out a new and improved inspector’s packet, designed to meet the participants’ need for better time-management and inspection-planning tools. The chief aim of the redesigned packet is to direct the inspector to areas of the laboratory that require the most attention. This is accomplished with the synopsis reports featuring key information about the laboratory. Other improvements include customized inspection materials that are duplicated for each team member.

“Instead of one packet for the whole team and you’re on your own, they’ve provided one for each [member],” Dr. Garon says. Each team member has his or her own customized, complete packet. “It includes both the general materials [inspectors] need, like the inspection guidelines, as well as the individual hospital-specific information they need.”

It was feedback from inspectors and participants who took part in focus groups that led to the improved packet design, says Caroline Maurer, project management analyst for the CAP. “We want to make sure our inspection teams are fully informed and prepared to conduct an objective and precise inspection,” she says. “We’re providing them with a snapshot, an overview of the laboratory and its key elements, to help guide them throughout the inspection process.”

Team leaders not only save time now because materials don’t have to be photocopied, but also need not worry about errors being made as they assemble packets. “It’s easy to overlook something and forget to copy it,” Dr. Garon says. “Then you’re shuffling around on the day of the inspection, asking, ‘Do you have this? Do you have that?’”

He says the time saved in copying and organizing materials can be better spent thinking about how to proceed on the day of the inspection, which will make things run more smoothly for the inspection team and the laboratory being inspected.

“When you’re actually doing the inspection, you’re going to have all of the relevant past material for that laboratory section right there in your hand. It helps you to focus on previous problem areas, things that have been theoretically fixed,” he says. “It helps you to target and plan how to approach the inspection.”

The packets will include more detail about the laboratories, such as the name of the relevant section head. Since section heads sometimes hold more than one position, if two inspectors needed to meet with them, scheduling headaches would sometimes result, Dr. Garon says. Before unannounced inspections, such arrangements could be made in advance, he notes, but not anymore. “This will facilitate your thinking.... You want to use your time as efficiently as you can.”

The new organizational tools should streamline the process for the inspection teams and those being inspected, Maurer says. “We’re addressing our customers’ demands and strengthening the consistency and precision of our inspections, with resulting benefits for our laboratories,” she says. “They can expect more consistency from one inspection to the next, and to have an inspection team that can more fully appreciate the key features of their laboratory” and their past performance.

Team leaders have been given a variety of new tools, Maurer says, one of which will assist them in organizing where their team members should be deployed. “It will give them an overview of the inspectors in the laboratory and their designated responsibilities.” They will also have a list of all qualified inspectors from their own laboratories. “As they assemble their team, they’ll know who they are, what they’re qualified to inspect, and their training status,” Maurer says.

The training of team leaders and team members is being strengthened under new requirements that took effect July 1, 2006 for team leaders and will take effect Dec. 31 of this year for all other inspectors. The CAP’s new training requirements will help ensure that all inspectors’ practices and findings are consistent and reliable and that best practices for inspections are applied consistently. In addition, training ensures that inspectors are aware of and understand the most recent Laboratory Accreditation Program changes.

Thousands of inspectors have completed the training in person or online during the past year, says Loretta Morrison, CAP director of education design and development. “We’ve been working on a lot of communication to describe the benefits of the training and get inspectors enrolled,” she says. “One of the advantages of the training is it helps ensure that across all the inspection teams and labs, we’re achieving a fairly high level of consistency in how we’re approaching the inspection, the methods we’re using, even down to the level of how we’re citing deficiencies versus making recommendations.”

More than 4,500 inspectors have completed online training in the past year. “It’s something anyone can take. All they need is access to a computer,” Morrison says.

The live, regional training sessions provide camaraderie and an opportunity for direct networking and dialogue among inspectors and the course faculty. “We’ve tried to build a number of venues that are convenient and tried to get the message across,” says Richard M. “Mick” Scanlan, MD, Pacific Northwest regional commissioner and member of the CAP Accreditation Education Committee. “The in-person sessions are still very popular. They’re highly enrolled.”

Whatever the educational format they choose, team leaders have gained numerous advantages in the past year, the CAP’s Morrison says. “They get all of the information they need to effectively lead and manage their teams, including information that is critical for them in terms of forming their teams.” A team leader checklist outlines the different responsibilities and the various items they need to look for. “The training also provides an extensive set of resources and tools that can be used throughout the inspection process, such as an interview protocol they can take with them and follow,” Morrison says.

“For a successful inspection, the team leader really is the key person for organizing the inspection and keeping it on track, and ensuring that the laboratory gets a full and thorough going over,” says Dr. Scanlan, residency program director and medical director of transfusion services, Oregon Health and Science University, Portland. “We have to teach them what to do before the inspection—how to build a team, how to guide that team through the inspection, and ensure good communication. Those are all very important.”

Team members have begun to enjoy many of the same benefits. Morrison says, “They can see, clearly laid out, what the inspection process is and what’s expected of them throughout the process. It provides them with the tools they’ll need and practice using the tools. It gives them practice in thinking through different scenarios that are likely to come up on an inspection, and lets them think about, ‘How would I handle this if I were on an inspection?’

“They get immediate feedback on whether that was the correct response and why it was correct, or why it was incorrect,” she adds. “It probably also gives them some ideas on how they might be able to change their practices in their own labs, thinking about how they maintain their own compliance and making sure they’re constantly in compliance. It provides insights into best practices.”

Even without the training requirement, many team leaders and members chose to enroll, but “we’re hoping to get to 100 percent,” Dr. Scanlan says. The faculty poses “various inspection scenarios. How would you approach this situation? The training teaches methods of eliciting information from laboratories, asking open-ended questions, following the specimen through the laboratory, [and] emphasizing fairness, consistency, and communication skills.”

“And there’s an ongoing commitment to stay trained,” he adds.

Ed Finkel is a writer in Evanston, Ill.