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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.

Inspection Options

In response to the global health emergency, we modified our laboratory inspection processes. The CAP now offers both an in-person and 100% virtual inspection. By offering innovative options to meet the needs of both laboratories and inspectors to complete the inspection process during the current climate, the CAP ensures safety and a collegial, educational inspection for all. Both inspection options result in a fully accredited laboratory.

Laboratories in good standing may participate in a virtual inspection by providing electronic access to their evidence of compliance with CAP checklist requirements. Reliable Wi-Fi connectivity in all areas of the laboratory is also required, along with access to a laptop, tablet, and/or smartphone—enabled with a camera, microphone, and speakers. International inspections will be completed virtually. Initial inspections for CLIA-licensed laboratories using a virtual inspection will require a focused on-site visit when restrictions allow per the Centers for Medicare & Medicaid Services.

How is Technology Used During an Inspection?

Use of technology such as document sharing, live streaming, and video conferencing is a necessity for a virtual inspection. Technology may also be incorporated into an in-person inspection. For example, using video conferencing for opening and summation conferences during an in-person inspection may make it easier for off-site personnel to participate.

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: Microsoft Teams, Zoom, or GoToMeeting.
  • Familiarity with the management of audio and screen sharing functionalities .

Document review may be accomplished by:

  • Screen sharing
  • Guest or read-only access to the laboratory’s document management system
  • File sharing of select documents via upload to the Laboratory's Organization Profile. Note: This option replaces the CAP’s SharePoint site.

View our Resources to Help Prepare for an Inspection for more information.

Planning for an Inspection

CAP staff is available to help laboratories and inspection teams navigate the best options for each unique situation. To kick off the planning, a call will be scheduled between the Laboratory Medical Director and the Team Leader approximately three to four months prior to the laboratory’s anniversary date. Topics discussed during this call may include:

  • Whether the inspection will be in person or virtual
  • Laboratory’s preference for document review—during the inspection, in advance, or a blend of both
  • Use of the CAP’s Inspection Planning and Document Tracking Tool
  • Key contacts for inspection planning and logistics

In-Person vs Virtual Inspections

In-Person InspectionVirtual Inspection
Eligibility CriteriaRestrictions on a country/state/local/institutional level must allow for an in-person inspectionMust be able to participate in live video stream of laboratory with audio and screen sharing available
Inspection Planning Call: Occurs 3-4 months prior to the CAP anniversary date.

The following items will be discussed:

  1. The inspection will be in person
  2. Determine timing of document review based on the laboratory's document review decision (during inspection, in advance, or a blend of both)
  3. Utilize the Inspection Planning and Tracking tool to help determine approximate amount of time required for each checklist and which, if any, documents will be shared prior to the inspection
  4. Identify laboratory contact(s) for sharing document management system, if applicable

The following items will be discussed:

  1. The inspection will be virtual
  2. Determine timing of document review based on the laboratory's document review decision (during inspection using screen sharing, in advance, or a blend of both)
  3. Utilize the Inspection Planning and Tracking tool to help determine approximate amount of time required for each checklist and which, if any, documents will be shared prior to the inspection
  4. Identify laboratory contact(s) for sharing document management system, if applicable
  5. Identify conference platform to be used and schedule a technology run through
  6. Identify laboratory contact(s) and corresponding team member(s) for interviews and observations
Opening Conference, Interviews, SummationIn PersonVideo Conference
Document ReviewAdvance (available 2 weeks prior to scheduled inspection date), during in-person inspection, or a blend of bothAdvance (available 2 weeks prior to scheduled inspection date), during virtual inspection using screen sharing, or a blend of both
Direct ObservationIn PersonVia live video stream
Total Inspection TimeAdvance document review, if applicable, may be performed in small blocks of time over the two weeks prior to the scheduled date of the in-person inspection. Total on-site inspection time is determined by the laboratory size and complexity, and whether any advance document review was completed.As determined by the laboratory size and complexity, the total inspection time is roughly equal to a traditional (in-person) inspection. Advance document review, if applicable, may be performed over two weeks in small blocks of time prior to the scheduled virtual inspection. The virtual inspection (ie, interviews, observations, and conferences) may be performed in small blocks of time over a one-week period.
Post-inspection ProcessNo change. Deficiency response due 30 days after Summation Conference.No change. Deficiency response due 30 days after Summation Conference.
Accreditation OutcomeAccreditedAccredited

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

Resources to Prepare for an Inspection

For inspectors and laboratories:

For inspectors:

  • Set aside 30 minutes to complete our “Performing Virtual Inspections: Being the CAP’s ‘Eyes and Ears’ from Home" supplemental training course.
  • Review our Inspector Planning and Document Tracking tool, customized for each Inspection Instance (II) to assist the inspection team in planning, sharing, and tracking the remote documentation requested and provided by the laboratory being inspected.
  • Inspector Training & Tools. Log into e-LAB Solutions Suite (eLSS) for additional resources in our Inspection Resources toolbox.

For laboratories:

Still have questions? Email us at lapassignments@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

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.

Summation SolutionsTake the Survey
Exploring and Eliminating ExpungementsTake the Survey
Inspecting Laboratory Director Responsibility: Delegation Junction What's Your Function? Take the Survey
Cite or Recommend? Know Before you Go! Take the Survey
Analytical Measurement Range (AMR): Inspecting Far and Wide Take the Survey
Inspecting Cytopathology: What you Might be Missing Take the Survey
Inspecting Reproductive Laboratory Accreditation Program (RLAP) Laboratories: Tips for the Clinical Inspector Listen to the podcast Take the Survey
Histocompatibility Checklist Changes and Key Points Take the Survey
Inspecting Safety: Is the Lab in Jeopardy? Take the Survey
Point-of-Care (POC): Inspection Strategies and R-O-A-D Maps Take the Survey
What Did You REALLY Mean…How to Write a “Good” Deficiency Take the Survey
Inspecting Alternative Performance Assessment (APA) in Laboratories Subject to US Regulations Take the Survey
Presenting Director Assessment Deficiencies: Best Practices Take the Survey
Identifying Systemic Issues – Critical Role of the Inspection Team Leader Take the Survey
Inspecting Method Validation/Verification Studies Take the Survey
Proficiency Testing Referral and Communications Take the Survey
Inspecting Method Comparison Studies Take the Survey
Inspecting Personnel Records Take the Survey
Inspecting Competency Assessment: Busting the Myths Take the Survey
12 Inspector Tools To Make Your Inspection Go More Smoothly Take the Survey
Inspecting Proficiency Testing Take the Survey
Documenting Your Inspection Findings Take the Survey
Competency Assessment Download the Toolkit (ZIP, 180 KB) Take the Survey

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)