September 2008
Laboratory Accreditation News

Anne Ford

Beginning last month, a new electronic feature on the CAP’s Laboratory Accreditation Program e-Lab Solutions site provides laboratories with online customized inspection checklists. Having those made-to-measure checklists will also provide a cure for the common affliction that Denise Driscoll, MS, MT(ASCP)SBB, CAP director of laboratory accreditation and regulatory affairs, terms “inspection day amnesia.”

“Sometimes when the inspector gets there and they ask you, ‘What’s your procedure for this?,’ all of a sudden your mind goes blank,” Driscoll, a former laboratorian herself, says. “You have no earthly idea. When your inspector puts you on the spot, you can’t remember.” With 18 accreditation program inspection checklists consisting of 3,200 questions, that’s far from surprising.

Of course, laboratories have received customized inspection checklists for years, but only in hard copy and only from the CAP. What’s new now is that labs can create their own tailor-made checklists online and download them in three different formats—PDF, Word, and Excel. This new functionality makes it easier for labs to annotate their checklists with comments about lab policies and procedures, making inspection-day amnesia much less likely.

R. Bruce Williams, MD, of the Delta Pathology Group in Shreveport, La., and chair of the CAP Commission on Laboratory Accreditation, explains: “If you just want the customized checklist written out, you could put it in a PDF. If you wanted to have a Word document, so you could make some comments or notations, that’d be fine. But this new service also allows you to download the customized checklist as an Excel spread­sheet. A lot of labs use something like that in order to assure themselves that they are meeting all the requirements and to provide documentation for the inspection team.” For instance, if there’s a requirement that quality control be performed daily, and if an Excel spread­sheet is used, one column might indicate where the quality control policy is kept. “The next column might be where you would find the quality control,” Dr. Williams says. “It might be that that month’s quality control is stored at the bench, this year’s is in the binder in the office, and the previous years’ are in the storage room down the hall, and you can note that in the spreadsheet.”

This is especially helpful for unannounced inspections, he notes. “When the inspector walks in and says, ‘Let me see your quality control information,’ you’d know exactly where to go. You wouldn’t have to wait for the supervisor. Anyone in the lab could look at the spreadsheet and help the inspectors find the information they are requesting.”

For laboratories, Driscoll says, the Excel format is more like a working tool. “They can cut and paste; they can add columns. They might want to put a column in and call it ‘procedure number,’ and they may want to do other columns that have to do with their compliance status, like ‘in progress,’ ‘complete.’ They can use their own codes, they can color it, they can sort it. You can’t sort easily with Word,” she notes.

The new electronic feature will do more than allow laboratories to customize their checklists to meet current requirements. Labs will also be able to re-create the checklists used during prior on-site inspections to see what questions should have been answered, Dr. Williams says. “Or you can go back and look at your customized checklist from your last self-inspection. It allows you to go back and see what you were doing a year ago, see what you should have been doing then, and compare that to what you’re doing now,” he says. “It’s really much more useful for the laboratories because they can select a point in time and see what their requirements are.”

Having access to a customized checklist at all times, not just before an on-site inspection, also helps ensure that laboratories address every question that applies to them. “Since this is customized, every question in there is something you’re required to abide by,” Dr. Williams points out. “So if you put comments by each one, then you know you’re not leaving out a question because you think it doesn’t apply.”

The CAP staffers who worked to make the new feature available have no worries that it will go unused. “This is definitely something that labs have been asking for,” says CAP checklist analyst Karen Peterson, MM, MLT(ASCP), MT(HEW), who managed the project. “I think it’s a unique tool we’re providing.”

“We think it’ll be wildly popular,” Driscoll adds. That’s why the Laboratory Accreditation Program is informing laboratories of the new capability in a series of e-mails over a six-week period, rather than announcing it to all 6,700 laboratories at once. “We don’t want to have any long queues” that would slow down a ­lab’s access to the site, she says. The Excel version calls up faster because it doesn’t have all the formatting that the Word version has.

Laboratories can look forward to more inspection-related electronic functionalities from the CAP in the future, including the ability to update activity menus online. “We’re moving very much to an online interface with our laboratories, so they will continuously know where they stand,” Dr. Williams says. He and other CAP leaders and staff hope that laboratories sign up for and participate in e-Lab Solutions because a lot of materials will be available there that will not be found on the general CAP Web site. “We hope by the time we get through with all we are doing,” Dr. Williams says, “the labs will find interacting with the College is even easier than it used to be.”

For more information on how to customize checklists online, visit www.cap.org and click on CAP Accreditation and Laboratory Improvement, or call the CAP at 800-323-4040 or 847-832-7000.