CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Dr. Sharkey, for his part, has an intuition for what is needed. His demeanor makes it plain that a CAP inspection is never pro forma and the effort they’ve made to prepare for it was well invested. Dr. Sharkey knows how to read a laboratory. Asking “How do you document this?” is far more likely to get someone talking than, “Do you do this?” he says. The checklists lay the groundwork, create the vocabulary, and ensure that we don’t miss anything. But genuine encounters are the motivators.
The Commission on Laboratory Accreditation, chaired by Walter Henricks, MD, oversees five committees that manage essential elements of the accreditation process. The Checklists Committee, chaired by William W. West, MD, is one of those, responsible for the accuracy and precision of roughly 3,000 total requirements. The language has to be succinct and the science has to be right. This group reviews current and recommended requirements every year, weighing advice from our scientific committees, translating government requirements, seeking advice from member experts across the CAP, and ensuring that the terminology is consistent across 21 checklist booklets. This year’s checklists will reflect several months of collaboration with experts to provide more guidance on forensic autopsies. Last year the deep dive was into new government requirements for individualized quality control plans. As Dr. West likes to say, “It’s a busy service.”
All of this falls under the umbrella of the Council on Accreditation, chaired by Bharati S. Jhaveri, MD. Dr. Jhaveri has been pivotal in growing the international accreditation program. Pathologists and technologists in laboratories we accredit want their inspectors to spend more time in small group education, Dr. Jhaveri says, and she is working toward that goal, looking to adjust the inspection calendar to meet that need.
Denise Driscoll, MS, MT(ASCP)SBB, senior director of laboratory accreditation and regulatory affairs, has 23 years of perspective on the staff side. She knows a great deal about the how and why of our approach. The checklists, she says, are “the gem at the heart of the entire program.” CAP accreditation, in her mind, is a marriage of the Council on Scientific Affairs (which provides the science behind all the requirements in the checklists) and the Council on Accreditation (which applies those requirements to laboratory practice). And what I would call the secret ingredient in this soup is what Denise calls the culture of the CAP, which provides accredited laboratories with all they need to create sound internal systems for quality management, error management, and root-cause analysis.
The CAP accreditation program has an elegant symmetry, embedding science in day-to-day practice within a culture that deeply values patient safety. It reflects a belief that every participant in every laboratory will take ownership of that goal and complete the same entry-level course: perspective-taking 101.
Dr. Williams welcomes communication from CAP members. Write to him at president@cap.org.