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

On This Page

Inspection Processes
Become an Inspector
Inspector Training
Inspector Packet Download and Resources
Inspection Process FAQs

Inspection Processes

Inspections

We support our inspectors and laboratories throughout the entire inspection process with our Inspector Training & Tools guidance resources in e-LAB Solutions Suite (ELSS) . There you will find:

Planning for an Inspection

The inspection process may begin with an inspection planning call, which occurs three to four months prior to the anniversary date of the laboratory. The likelihood of this call is dependent on the complexity of the laboratory. We encourage the team leader to work directly with the laboratory director, although the CAP can assist with the planning call upon request. The planning call will:

  • Help establish the approximate amount of time required for each checklist and which, if any, documents will be shared prior to the inspections through our Inspection Planning and Tracking tool
  • Establish the need for team member subspecialty expertise and whether additional team members need to be sourced through the CAP.
  • Address any additional logistics questions.

How Inspectors Should Plan

  • Review the Inspector Packet. An electronic copy is available on the Inspector Packet Download webpage. The electronic inspection packet allows team leaders to easily distribute up-to-date inspection materials to team members.
  • View our Inspector Essentials and Tips. Through real-life scenarios and knowledge checks to gauge proficiency, these short modules help you better understand key topics related to laboratory inspections.
  • Encourage your staff to take the inspector training course and join your inspection team. The inspection process is a valuable learning experience for all laboratory staff.
  • Mentor residents through an inspection. Residents benefit from joining an inspection team by learning laboratory best practices, deepening their pathology skills, and connecting with other pathologists. Learn more about how residents can participate.

How Laboratories Should Plan

  • View the CAP’s archived Focus on Compliance webinars . Stay up to date and gain an understanding of the complex and ever-changing rules of compliance as well as best practices to improve laboratory operations.
  • Explore our Inspector Training & Tools resources in e-LAB Solutions Suite (ELSS) .

Advance Document Review

Laboratories have the option to utilize the advance document review. If this option is chosen, inspection teams should incorporate it into their process. If a laboratory opts to not use the advance document review, inspectors and the laboratory should prepare for an on-site document review. The dates of the advance document review must be decided upon by the team leader and laboratory director. Advance document review may be performed in small blocks of time in the two weeks prior to the inspection. Inspection teams should anticipate spending an equivalent amount of time on the advance document review as they would during an on-site document review.

The Inspection

Laboratories are inspected every two years. In the year when an on-site inspection does not occur, the laboratory performs a self-inspection using materials provided by the CAP. The CAP partners with its laboratories, ensuring each has the framework and direction needed to achieve and maintain accreditation.

Inspection Notification

The CAP adheres to the following notification processes:

  • All CAP-accredited laboratories affiliated with an institution accredited by The Joint Commission will be notified up to 14 days prior to their inspection for US/Canada laboratories, per the CAP’s current collaborative agreement with The Joint Commission
  • All other CAP-accredited laboratories will be notified up to two weeks prior to the scheduled inspection as part of the CAP’s deemed status with the Centers for Medicare and Medicaid Services (CMS). CMS requires that a laboratory be notified of an inspection no sooner than two weeks to the date of the inspection.
  • For laboratories outside the US and Canada, as well as any facilities accredited through the CAP’s Forensic Drug Testing, Biorepository, or Reproductive Accreditation Programs, the inspection date notification will not change; these laboratories and facilities will continue with their current inspection date notification process, as will all laboratories undergoing their first inspection.

After the Inspection

Once the inspection has ended, inspectors and laboratories should, respectively, do the following.

What Inspectors Need to do

  • Finalize the Inspection Summation Report
  • Fill out and submit your expense report to the CAP

What Laboratories Need to do

  • Fill out the post-inspection critique
  • Respond to any deficiencies cited in the Inspection Summation Report within 30 days.
  • View our Online Deficiency Response tutorial videos and read our FAQ to learn more about how to enter and respond to these deficiencies.

Questions? Read our FAQs or email us at accred@cap.org.

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

Update My Profile

Register for 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. Through our revamped education method, you are prescribed a customized pathway, focused on your individual learning needs. Separate courses are available for team leaders and team members. These courses are updated annually to ensure alignment with CAP checklists. CME 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

Inspector Essentials and Tips

To supplement the inspector training courses, Inspector Essentials and Tips mini-training vignettes use real-world examples to provide practical approaches to new and perplexing topics.

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

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

Download International Travel Tip Sheet (PDF) Questions? Email us at accred@cap.org.

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