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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.
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:
- Inspection preparation worksheets, guidelines, tip sheets, and other templates
- Answers to the most common checklist questions
- Team Leader and Team Member Training
- Laboratory Inspection Preparation: Getting Ready for Your First Inspection Course
Planning for an Inspection
The inspection process may begin with an inspection planning call, which occurs 3–4 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 Fast Focus on Compliance vignettes. Through situational scenarios and knowledge checks to gauge proficiency, these short modules help inspectors acquire an understanding and gain insight into specific 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 one hour prior to their inspection, 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:
- Update your online profile to request to be an inspector
- 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. 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.
- Team Leader Inspector Training – designed for board-certified pathologists or PhDs assigned to lead a CAP inspection team
- Team Member Inspector Training – designed for experienced laboratory professionals participating on a CAP inspection team
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
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
For inspectors to review prior to planning international travel for inspections:
Inspection Notification Process
- Open all
- Close all
The CAP maintains 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.
The CAP also has other agreements with accrediting agencies, such as The Joint Commission, that may further impact when notification can be provided. The current collaborative agreement with The Joint Commission stipulates that all CAP-accredited laboratories affiliated with a Joint Commission-accredited institution will be notified one hour prior to inspection.
All CAP-accredited laboratories must be inspected every two years.
Per the agreement between the CAP and The Joint Commission, the CAP will provide notification one hour prior to inspection for US/Canadian laboratories that meet both of the following criteria:
- Affiliated with a Joint Commission-accredited institution
- Accredited with the CAP Laboratory Accreditation Program
Per CMS guidance, the CAP will provide notification two weeks prior to the scheduled inspection for US/Canadian laboratories that meet all of the following criteria:
- Certified by CLIA
- Accredited with the CAP Laboratory Accreditation Program
- Not receiving their initial CAP inspection
- Not affiliated with a Joint Commission-accredited institution
The CAP will continue to provide notification as soon as an inspection date is set for laboratories that meet any of the following criteria:
- Those receiving their initial CAP Accreditation Program inspection and which have not joined an existing CAP-accredited group
- Those outside the US or Canada
- Those in the Biorepository Accreditation Program
- Those in the Forensic Drug Testing Accreditation Program
- Those in the Reproductive Laboratory Accreditation Program
One-hour notifications
- On the first day of inspection, the inspection team will call one hour before arriving at the laboratory. They will use the one-hour inspection notification number provided by the primary location in their Organization Profile.
- At approximately 7:00 AM local time on the first day of inspection, the CAP will send email confirmations to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
Two-week notifications
- The CAP will send an email notification 14 days prior to the first day of inspection to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
- On the first day of inspection, the inspection team will call one hour before arriving at the laboratory. They will use the one-hour inspection notification number provided by the primary location in their Organization Profile.
- At approximately 7:00 AM local time on the first day of inspection, the CAP will send email confirmations to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
Inspection date set notifications
- As soon as the inspection date is set by the inspection team, the CAP will send an email notification to the following contacts:
- Inspection Team Leader
- Inspection Coordinator
- Laboratory Director (from group’s Primary location)
- Administration/Manager (from group’s Primary location)
- Accreditation Contact (from group’s Primary location)
- Quality Contact (from group’s Primary location)
- On the first day of inspection, the inspection team will call one hour before arriving at the laboratory. They will use the one-hour inspection notification number provided by the primary location in their Organization Profile.
- At approximately 7:00 AM local time on the first day of inspection, the CAP will send email confirmations to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
The inspection date may be changed after notification if inspection team members encounter health- or travel-related difficulties. If this occurs, a notification email will be sent as soon as possible to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
General Inspection Process Information
- Open all
- Close all
The inspection window for laboratories in any CAP accreditation program is 90 days, whether for their initial inspection or any subsequent routine inspection for reaccreditation. The anniversary date of a laboratory’s inspection is 89 days from the previous inspection.
An inspection group’s primary location/laboratory can submit up to 10 blackout dates during the application/reapplication process. Once the application/reapplication has been completed and submitted, those dates cannot be changed.
The CAP will honor national holidays that occur in an inspection window.
Changes/updates may be made throughout the application/reapplication process. However, once the application/reapplication has been completed and submitted, those dates can no longer be changed.
Currently, team leader information (including the institution/group providing the inspection team) is sent to laboratories via letter; later this year, this notification will transition to email.
A laboratory may complete a conflict of interest form, located with the self-evaluation materials, and return it to the CAP at accred@cap.org.
A laboratory may also request their already-submitted conflict of interest information at any time by emailing the Inspection Assignments Group at accred@cap.org. The Inspection Assignment Specialist will reply with an email that includes a report of any existing conflicts. This information can then be updated with additions or deletions and re-submitted to the Inspection Assignment Specialist at accred@cap.org.
Joint Commission-Affiliated Laboratories and Inspections
- Open all
- Close all
Laboratories in institutions that are accredited by The Joint Commission are considered to have a relationship with them. Laboratories must report this information to the CAP in their Organization Profile; see the Licensure and Certification section under Other Accreditors.
Please add this information to your Organization Profile in e-LAB Solutions Suite (ELSS).
No, even if only one site in a group inspection has a relationship with The Joint Commission, all sites will receive the one-hour notification.
If a laboratory separates from the group, it will no longer be coordinated with the others in the group. The laboratory would have the same 90-day window, but two separate teams would be responsible for their inspections.
Questions? Email us at accred@cap.org.
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:
- Inspection preparation worksheets, guidelines, tip sheets, and other templates
- Answers to the most common checklist questions
- Team Leader and Team Member Training
- Laboratory Inspection Preparation: Getting Ready for Your First Inspection Course
Planning for an Inspection
The inspection process may begin with an inspection planning call, which occurs 3–4 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 Fast Focus on Compliance vignettes. Through situational scenarios and knowledge checks to gauge proficiency, these short modules help inspectors acquire an understanding and gain insight into specific 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 one hour prior to their inspection, 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:
- Update your online profile to request to be an inspector
- 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. 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.
- Team Leader Inspector Training – designed for board-certified pathologists or PhDs assigned to lead a CAP inspection team
- Team Member Inspector Training – designed for experienced laboratory professionals participating on a CAP inspection team
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
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
For inspectors to review prior to planning international travel for inspections:
Inspection Notification Process
- Open all
- Close all
The CAP maintains 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.
The CAP also has other agreements with accrediting agencies, such as The Joint Commission, that may further impact when notification can be provided. The current collaborative agreement with The Joint Commission stipulates that all CAP-accredited laboratories affiliated with a Joint Commission-accredited institution will be notified one hour prior to inspection.
All CAP-accredited laboratories must be inspected every two years.
Per the agreement between the CAP and The Joint Commission, the CAP will provide notification one hour prior to inspection for US/Canadian laboratories that meet both of the following criteria:
- Affiliated with a Joint Commission-accredited institution
- Accredited with the CAP Laboratory Accreditation Program
Per CMS guidance, the CAP will provide notification two weeks prior to the scheduled inspection for US/Canadian laboratories that meet all of the following criteria:
- Certified by CLIA
- Accredited with the CAP Laboratory Accreditation Program
- Not receiving their initial CAP inspection
- Not affiliated with a Joint Commission-accredited institution
The CAP will continue to provide notification as soon as an inspection date is set for laboratories that meet any of the following criteria:
- Those receiving their initial CAP Accreditation Program inspection and which have not joined an existing CAP-accredited group
- Those outside the US or Canada
- Those in the Biorepository Accreditation Program
- Those in the Forensic Drug Testing Accreditation Program
- Those in the Reproductive Laboratory Accreditation Program
One-hour notifications
- On the first day of inspection, the inspection team will call one hour before arriving at the laboratory. They will use the one-hour inspection notification number provided by the primary location in their Organization Profile.
- At approximately 7:00 AM local time on the first day of inspection, the CAP will send email confirmations to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
Two-week notifications
- The CAP will send an email notification 14 days prior to the first day of inspection to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
- On the first day of inspection, the inspection team will call one hour before arriving at the laboratory. They will use the one-hour inspection notification number provided by the primary location in their Organization Profile.
- At approximately 7:00 AM local time on the first day of inspection, the CAP will send email confirmations to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
Inspection date set notifications
- As soon as the inspection date is set by the inspection team, the CAP will send an email notification to the following contacts:
- Inspection Team Leader
- Inspection Coordinator
- Laboratory Director (from group’s Primary location)
- Administration/Manager (from group’s Primary location)
- Accreditation Contact (from group’s Primary location)
- Quality Contact (from group’s Primary location)
- On the first day of inspection, the inspection team will call one hour before arriving at the laboratory. They will use the one-hour inspection notification number provided by the primary location in their Organization Profile.
- At approximately 7:00 AM local time on the first day of inspection, the CAP will send email confirmations to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
The inspection date may be changed after notification if inspection team members encounter health- or travel-related difficulties. If this occurs, a notification email will be sent as soon as possible to the following contacts for each laboratory:
- Laboratory Director
- Administrator/Manager
- Accreditation Contact
- Quality Contact
General Inspection Process Information
- Open all
- Close all
The inspection window for laboratories in any CAP accreditation program is 90 days, whether for their initial inspection or any subsequent routine inspection for reaccreditation. The anniversary date of a laboratory’s inspection is 89 days from the previous inspection.
An inspection group’s primary location/laboratory can submit up to 10 blackout dates during the application/reapplication process. Once the application/reapplication has been completed and submitted, those dates cannot be changed.
The CAP will honor national holidays that occur in an inspection window.
Changes/updates may be made throughout the application/reapplication process. However, once the application/reapplication has been completed and submitted, those dates can no longer be changed.
Currently, team leader information (including the institution/group providing the inspection team) is sent to laboratories via letter; later this year, this notification will transition to email.
A laboratory may complete a conflict of interest form, located with the self-evaluation materials, and return it to the CAP at accred@cap.org.
A laboratory may also request their already-submitted conflict of interest information at any time by emailing the Inspection Assignments Group at accred@cap.org. The Inspection Assignment Specialist will reply with an email that includes a report of any existing conflicts. This information can then be updated with additions or deletions and re-submitted to the Inspection Assignment Specialist at accred@cap.org.
Joint Commission-Affiliated Laboratories and Inspections
- Open all
- Close all
Laboratories in institutions that are accredited by The Joint Commission are considered to have a relationship with them. Laboratories must report this information to the CAP in their Organization Profile; see the Licensure and Certification section under Other Accreditors.
Please add this information to your Organization Profile in e-LAB Solutions Suite (ELSS).
No, even if only one site in a group inspection has a relationship with The Joint Commission, all sites will receive the one-hour notification.
If a laboratory separates from the group, it will no longer be coordinated with the others in the group. The laboratory would have the same 90-day window, but two separate teams would be responsible for their inspections.
Questions? Email us at accred@cap.org.