System Inspection Option

As health systems grow, standardizing laboratory practices across all sites can improve efficiency, patient satisfaction, quality of care, and overall clinical operations. With our System Inspection Option, the CAP will not only ensure that you’re meeting regulatory requirements, but through our unique peer inspection model—which uses a team of inspectors from another integrated care network—we’ll also provide an independent assessment of your system’s standardization.

The System Inspection Option offers participants:

• The same edition of the Accreditation Checklists across all laboratories
• A true peer inspection performed by other integrated health care networks
• Consistent inspectors across all disciplines and sites, plus a CAP Inspection Specialist
• The same week-long inspection date range for all labs  
• A global summation conference to focus and prioritize work efforts across the system
• An assessment of integrated services to promote standardization
• A dedicated Technical Specialist and Regional Commissioner to ensure a consistent post-inspection review process

One System Inspection Means One Reciprocal Team

Never to be overlooked, a primary benefit of the System Inspection Option is that it puts all your laboratories on the same inspection cycle, drastically reducing the number of open inspection windows you have throughout the accreditation cycle. Perhaps more importantly, your entire enterprise would only be required to assemble one inspection team every 18 to 24 months.

• A pre-inspection planning meeting—conducted either virtually or in-person, (at the System’s discretion) by a CAP Inspection Specialist—ensures an inspection team appropriate in size and scope
• A CAP Inspection Specialist participates in the on-site inspection to facilitate communication and ensure a consistent process
• In addition to the site-specific summation conferences, a post-inspection global summation conference provides system-level feedback on integration and system-level issues
• Laboratories receive a CAP system inspection certificate to signify successful participation
• The System Inspection Option follows the same two-year cycle using the peer-based inspection model and checklist requirements of the CAP Laboratory Accreditation Program
   

Eligibility for the CAP System Inspection Option is open to highly-integrated groups of affiliated laboratories that, in total, offer a comprehensive scope of services in anatomic pathology, cytology, and clinical disciplines; are located within a three-hour drive from a centrally-located laboratory; have a common administration and ownership; are enrolled in the CAP Laboratory Accreditation Program; and meet at least six of the eight following criteria:

• One set of administrative policies for the system
• A single management team for the system
• A system-wide competency assessment program
• A system-wide quality improvement program
• A system-wide quality control program
• A common approach to management of patient data (eg, LIS/HIS/eMR)
• A system-wide safety program
• A system-wide process to manage sample collection and test requests

We understand that new systems may not initially be fully integrated for all of the eight criteria; however, we expect that the system will progress toward full integration over time.

There is a one-time application fee, plus a yearly system fee based on the number of laboratories in your system. This is in addition to each laboratory’s individual accreditation fees.