To oversee preinspection and inspection processes to improve the timeliness and quality of inspections:
- Assure program policies regarding inspection assignments are consistent and objective.
- Establish metrics and monitor the timeliness and effectiveness of Inspector Assignments and Inspections.
- Establish and monitor a process for conducting validation inspections for which feedback on the effectiveness of assignments, education and other program initiatives could be assessed and serve as input for program improvement.
- Establish algorithms for effective team assignment, which gives consideration to several factors including but not limited to laboratory size and complexity, accreditation status, conflicts of interest, experience of team members, and the laboratory and inspecting team's laboratory's projected risk of noncompliance. These factors may result in the assignment of expert inspector(s), including staff, to supplement or replace an assigned local team.
- Oversee specialty program assignments (ie, Inter-Region, Children's Hospitals, RLAP, FDT, BAP, Systems, International).
- Provide guidance for the development of inspector tools designed to improve inspection effectiveness and documentation of deficiencies. This function includes establishing standards for preinspection review of laboratory information (e.g., Quality Manual), and translation of gathered data into actionable direction for the inspection team. Note: The "inspection tools" or Checklist component is specifically the responsibility of the Checklist Committee.
- Provide input to the ongoing refinement of the application/reapplication process and tools including eventual conversion to an Internet-based process.
- Monitor and assess the effectiveness of the inspection methods, including in-person inspections, in-person inspections with advanced document review, virtual inspections, and virtual inspections with advanced document review.
- Develop and oversee inspector management programs, including inspector credentialing, mentoring, feedback mechanisms, recognition programs, do not use process, and identification of inspection team rosters prior to inspection, and other board-approved initiatives assigned to the committee.
|Time Commitment Requirements|
|Number of face-to-face meetings||3|
|Length of meetings||1 day|
|Typical meeting days||Thursdays and Fridays|
|Meeting locations||One meeting takes place in Chicago and the others take place in two other locations.|
|Number of conference calls||9, in the months that do not have a meeting|
|Hours/year of committee work required outside of meetings||12|
|Additional travel or time commitments||Attendance by the chair at Council on Accreditation meetings.|
Activities of Committee
- Oversees and endorses materials created for the development of the inspection process, e.g., inspector packet.
- Defines the policies for the program related to inspector assignment and inspection process.
- Reviews inspection assignment and on-time inspection statistics.
- Evaluates "Do Not Use Inspectors" and requests for changes to Specialties and Specialty Inspector requirements
- Reviews outcomes of validation inspections and performance measures
- Reviews outcomes of the Laboratory Accreditation Program inspection process and makes recommendations for improvement as appropriate.
- Oversees and endorses inspector management program and associated policies, including annual Inspector Recognition Program.
Expertise or Experience
- Knowledge of inspection preparation through conducting inspections
- Knowledge of laboratories
- Some knowledge of accreditation process through experience as a laboratory director of a CAP-accredited laboratory, or experience as a State or Regional Commissioner
Benefits of Committee Membership
- Gain experience in the development of inspection process initiatives and implementation
- Opportunity to publish materials
- Opportunity to speak at education events
Representation on Committee Beyond the CAP
- Liaison representation on the Council on Accreditation as appointed