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Inspector Tools and Training

The CAP relies on its partnership with our volunteer inspectors to offer an educational, peer-based approach to inspections. Our inspectors share their expertise to reduce risk and improve patient care. Their hard work, knowledge, and steadfast commitment to quality are invaluable assets to our Accreditation Programs.

2020 Modified Inspection Processes

In response to the global health emergency, we have modified our laboratory inspection processes. In addition to a traditional inspection, the CAP now offers a hybrid and virtual inspection model. Both make use of technology to complete a portion or all of the inspection process.

We worked to modify our processes, maintaining our thorough and educational inspections while meeting the Centers for Medicare & Medicaid Services requirements for an on-site presence for CLIA licensed laboratories. Inspections for international non-CLIA laboratories will be virtual.

By modifying our inspection processes, we provide:

  • Safety for both inspectors and the laboratory, including smaller teams for the on-site portion of the inspection.
  • Opportunities for peer exchange, a hallmark of the CAP inspection process.
  • Assurance that laboratories remain in continued compliance with accreditation requirements.

The inspection period will be agreed upon between the inspection team and the laboratory inspected. The total inspection time for a hybrid and virtual inspection should be roughly equivalent to the total time for a traditional onsite inspection plus time upfront for planning. Using the CAP’s tools and templates will help streamline your upfront planning.

We were anxious to get our inspection behind us and appreciated the CAP’s flexibility with modifications to the inspection process. Overall, the benefits far exceeded the drawbacks. Our team felt a sense of normalcy once the inspection was complete.

Ed Reineks, MD, PhD, DABCC, FCAP
Medical Director, Point of Care Testing
Cleveland Clinic

How Technology is Used During a Hybrid or Virtual Inspection

Like a traditional on-site inspection, both the hybrid and the virtual models utilize all aspects of the CAP’s R.O.A.D. inspection methodology, but also rely on video conferencing, digital file transfer, and live streaming.

Live streaming requirements for laboratories include:

  • Two-way audio and video capabilities at the location the activity is performed (may be in various laboratory areas), with Wi-Fi connectivity in each area.
  • Access to one of the following web-conferencing solutions: Skype, Microsoft Teams, Zoom, or GoToMeeting. 
  • Familiarity with the management of audio and screen sharing functionalities before your inspection to avoid unnecessary delays.

The remote interactive document review may be accomplished by:

  • Guest or read-only access to the laboratory’s document management system.
  • File sharing via CAP SharePoint site

Comparing Our Hybrid and Virtual Inspection Processes

Hybrid InspectionVirtual Inspection
Eligibility CriteriaNoYes
Document ReviewVirtualVirtual
Direct ObservationOnsiteVirtual using livestream
Inspection PeriodUp to one (1) week for remote document review phase, followed by a one- or two-day onsite inspection within two weeks of completing the document review.As agreed by the Inspection Team Leader and Laboratory Director. Not to exceed one week.
Total InspectionTotal inspection time roughly equal to traditional onsite inspection.Total inspection time roughly equal to traditional onsite inspection.
Post-inspection ProcessNo changeNo change
Accreditation OutcomeAccreditedAccredited. An onsite visit will be scheduled within six (6) months or when feasible.

Hybrid Inspection Process Overview

Our hybrid inspection consists of a remote document review followed by an on-site inspection focused on the direct observation portion of the inspection. Opening and summation conferences and executive interviews may be completed using video or conference calls.

Upon completion of the hybrid inspection process, the laboratory is fully accredited and should maintain continuous compliance for the remainder of the two-year accreditation cycle.

Virtual Inspection Overview

When it is not possible for an inspection team to come onsite, the CAP may conduct a virtual inspection followed by an on-site visit, as required for CLIA laboratories, four to six months after, or once it is safe to do so. The on-site inspection is not meant to be another full inspection and will focus on direct observation of testing procedures that are unable to be accomplished virtually.

While direct observation may be the most challenging part of a virtual inspection, it can be accomplished with a mix of live streaming, post-audit reviews, and technical interviews.

Laboratories participating in the virtual inspection option must meet the following eligibility criteria:

  • Be in good standing.
  • Able to provide electronic access to their evidence of compliance with CAP checklist requirements
  • Availability and reliable connectivity of Wi-Fi in each laboratory area.
  • A laptop, tablet, or smartphone, enabled with a camera, microphone, and speakers.

Upon completion of the virtual inspection, the laboratory will be accredited with the requirement to successfully undergo an on-site visit within six months or once it is feasible to fulfill the CLIA requirement of an on-site inspection.

Laboratories not subject to the US CLIA regulations will not have a mandatory on-site inspection, unless it is determined that the virtual inspection could not adequately determine a laboratory’s compliance with CAP accreditation requirements. In this instance, the CAP reserves the right to conduct an on-site inspection

Post-Inspection Process and Accreditation Outcome

There are no changes to the post-inspection process for either model. Once complete, the laboratory is fully accredited for a two-year accreditation cycle.

Resources and Additional Information for Modified Inspections

Inspection resources and additional information for both the hybrid and virtual models have been added to the Inspector Tools and Training section on e-LAB Solutions Suite (ELSS) on cap.org, including a new inspector supplemental training course, Performing Virtual Inspections: Being the CAP's ‘Eyes and Ears’ From Home. Inspectors should set aside 30 minutes before performing their first hybrid or virtual inspection to complete this supplemental course.

Laboratories planning to be inspected virtually should set aside 30 minutes to gain insight about what to expect in Being Inspected Virtually: Demonstrating CAP Accreditation Compliance in an Electronic World.

Still have questions? Read our Frequently Asked Questions

Become an Inspector

CAP inspectors have the opportunity to observe and learn from a variety of laboratory environments. You’ll gain fresh insight into best practices that you can take back to your laboratory plus you’ll be better prepared to identify gaps in your own compliance efforts helping you to prepare for your laboratory’s inspection.

Being a CAP inspector has helped me become a better medical technologist and supervisor. I’m now intimately familiar with checklist requirements. But more important, I know how to apply this knowledge to improve quality and enhance patient care.

Technical Supervisor, Reference Laboratory

If you work in a CAP-accredited laboratory and would like to inspect, just follow these simple steps:

  1. Update your online profile to request to be an inspector
  2. Complete a mandatory inspector training course

Only the CAP makes use of specialty inspectors for highly complex specialties such as:

  • Molecular pathology
  • Clinical biochemical genetics
  • Cytogenetics
  • Histocompatibility
  • Flow cytometry

Specialty inspectors truly understand the issues and technology of their specialty, providing valuable insight and practical advice to the laboratory being inspected. Be sure to indicate in your profile if you are interested in becoming a specialty inspector. CAP Scientific Resource Committees approve specialty inspectors.

Inspector Training

Our inspector training courses not only provide you with tools and techniques to be a successful inspector, they may also aid your own compliance and quality initiatives. Separate courses are available for team leaders and team members. These courses are updated annually to ensure alignment with CAP checklists. CME/SAM and CE available.

I found the course to be challenging and instructive, even for an experienced inspector. The scenarios were practical and related to real world situations requiring timely decisions. Very useful exercise!

Pathologist Team Leader

Virtual Inspection Inspector Training

Our supplemental training course for virtual inspections helps you adapt your inspection expertise to a virtual environment. Prepare for your first virtual inspection with our new 30-minute training course, Performing Virtual Inspections: Being the CAP’s “Eyes and Ears” from Home

Fast Focus on Compliance Mini-training Vignettes

To supplement the inspector training courses, Fast Focus on Compliance mini-training vignettes give inspectors practical approaches to handle new and perplexing topics using real-world examples.

Inspector Packet Download and Resources

Team leaders download and easily share with your team an up-to-date version of the inspection packet. You’ll also be able to view all of your upcoming inspections and your inspection history.

Download Inspection Packets for Team Leads Lock Arrow Right

For inspectors to review prior to planning international travel for inspections:

Download International Travel Tip Sheet (PDF)