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CAP Inspection Process Modification for Team Leaders

Due to the COVID-19 global pandemic, the College of American Pathologists (CAP) is recommending a modified inspection process to adapt to the current climate in health care and to provide for increased safety measures.

To facilitate this new process our inspection team leaders will communicate with laboratories scheduled to be inspected to ensure:

  1. Access to the facility on inspection day(s)
  2. Adherence to safety precautions

Recommended changes:

  • Addition of a pre-inspection document review step
  • Review of the 2020 Modified Inspections Toolkit

We encourage all laboratories to adopt the addition of a document review step (refer to the 2020 Modified Inspections Overview document below) prior to the on-site inspection. This document review step will:

  • Decrease the number of inspectors needed for the on-site visit and
  • Allow the exchange of ideas and dialogue that are the hallmarks of CAP accreditation inspections

To help our inspectors prepare for inspections and understand the recommended inspection process modifications, the CAP has developed a 2020 Modified Inspections Toolkit. The toolkit provides guidance for some of the common questions and concerns raised regarding expectations for performing inspections. It can be found on the Inspector Tools & Training page within the Accreditation Resources in e-LAB Solutions Suite at cap.org. The toolkit includes:

  1. 2020 Modified Inspections Overview – Provides an overview of the CAP’s modified inspection process (including the new document review step) for inspectors and laboratories (audience: inspectors and laboratory staff)
  2. Inspection scenarios – Identifies common inspection scenarios likely to be encountered and frequently asked questions about regulatory requirements to help guide you on how to respond to such situations (audience: inspectors and laboratory staff)
  3. Document Review Tip Sheet – Outlines the proposed process change for performing a document review prior to the on-site inspection (audience: inspectors)
  4. Document Review Tracking Sheet – Enables recording of any concerns or question or additional information that will need to be evaluated at the on-site inspection (audience: inspectors)
  5. Inspection Planning Tip Sheet – Outlines some of the changes and/or new considerations for planning inspection teams if the modified inspection process is used (audience: inspectors)
  6. Travel Planning Tip Sheet – Outlines suggestions for consideration when traveling or planning travel for an inspection (audience: inspectors)
  7. Inspection Tip Sheet – Outlines changes to the inspection process (audience: inspectors)

The CAP strongly recommends you review this toolkit with your team members. Please contact us at accred@cap.org with any questions.