Originally published in CAP
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."
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
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
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
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.
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,"
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
Ed Finkel is a writer in Evanston, Ill.