Navigating the CAP checklist in preparation for an on-site inspection can be very overwhelming. Whether this is our first time leading your lab in this process, or you are a pro- here are some of my tips that I hope will make your job easier so that you are prepared and ready for a successful inspection!
Tip 1: Print the Checklist (on actual paper): The first step in the process in our lab is our CAP authorized user will print all of the checklists and distribute them department leads so that everyone has the chance to review them.
Tip 2: Review the Material and Make Notes: Each department lead should go through the printed copy of the checklist and write down where the required material can be found. We do this for everything, whether it is a log sheet or book, policy (electronic or paper), examples of reports, etc. If you cannot find an answer to the CAP checklist requirement you need to make sure that it is included in a policy or you have the evidence of compliance (usually both are required). It is not necessary to have a separate policy for every requirement but make sure it is embedded into the proper policy.
For example, ANP.21397: The Laboratory prevents cross-contamination of specimens in the histology laboratory. Make sure there are steps addressed in your policy to prevent cross-contamination during the various phases of tissue handling. I have steps addressed in our grossing policy, embedding policy, cutting policy and frozen section policy to make sure instruments are clean and well maintained and floatation water baths are cleaned between cases. Also address processes for handling of blocks and labeling of slides to prevent specimen mix-ups.
Tip 3: Conduct a Mock Inspection: A mock inspection is a great way to make sure that they are inspection ready. This helps the entire system know if they have all their i’s dotted and t’s crossed and are inspection ready!!! You will want to make sure logs are being filled out every day, make sure all policies and procedures are being followed by your staff all the time so it natural for them during inspection, make sure your competency records are up to date, make sure you are following the appropriate record retention for reports, blocks, slides and wet tissues. Have the appropriate records for Quality Control always up to date.
Tip 4: Color Code Your Evidence of Compliance: When you have all the checklist requirement answers filled out on paper checklist, have the CAP authorized user for your site download the checklist to an excel spreadsheet. It will have your Laboratory location, Section/Department, LAP number, Accreditation Unit ID, Section Unit ID, Checklist, Edition Date and Print date. Using the answers written in the paper copy, I type in the Evidence of Compliance section the Policy associated with the requirement or where to find the Evidence of Compliance. I use a key of typing the answer in Red for policy name or Blue for where to find the evidence of Compliance.
Tip 5: Compile Your Information: I put the completed checklist in a binder (along with the key as to the color answers) and some of the simple evidence of compliance, like copies of logs for staining line log for changing solutions or temperature logs from a certain month in the flaps of the binder. I also print samples of Surgical Path reports to demonstrate some of the requirements needed as Cancer protocols, gross descriptions, signed by Pathologist, etc.. This binder is for the use of the CAP Inspection team on the day of the inspection. It makes it very easy for them to have all the information at their fingertips and makes the day go smoother.
Tip 6: Share the Information: Make sure you have provided copies, or informed others in your lab where this document is located. This will help staff so they are prepared in case you are not available on the day of inspection.
I have actually had several inspectors take these tips back to their own labs. It also makes it easier to keep the binder and the paper copy for the next self inspection or on-site inspection, updating with new or revised checklist requirements as necessary.
Good luck on Inspection Day!!!
Written By: Dawn D. Schneider, HT(ASCP)
#2023#Blog#LaboratoryOperations