System Inspection Option FAQs

Highly integrated, full-service laboratories which offer services in the following areas are eligible for the CAP System Inspection Option:

• Chemistry, hematology, microbiology, blood banking, anatomic pathology (surgical pathology), and/or cytopathology
• Anatomic pathology (surgical pathology) laboratories with a separate CLIA license
• Affiliated limited service, blood gas, and point of care laboratories within the system

For example, a system comprised of only point of care laboratories not affiliated with two or more full-service laboratories is not eligible for the System Inspection Option.

The CAP understands that new systems may not be fully integrated for each of the criteria listed below; however, we expect that the system will progress toward full integration over time.

At the time of application, 100% of system laboratories meet or are progressing toward six of the eight integration criteria below.

• One set of administrative policies for the system
• Single management team for the system
• System-wide competency assessment program
• System-wide quality improvement program
• System-wide quality control program
• Patient data managed using a common approach
• System-wide safety program
• System-wide specimen collection manual

All system laboratories must be within a three-hour driving distance from a centrally located laboratory within the system (does not have to be the primary laboratory).

Unfortunately, we do have to restrict the System Inspection Option to this geographic distance requirement for logistics reasons. If your system exceeds this geographic requirement, we can work with you to distribute your laboratories across two systems (or as many as needed) so that all your sites can participate in and benefit from a systems inspection.

It is not a requirement that laboratories have standardized instrumentation across all sites, though many of our system customers find significant monetary and other operational benefits by doing so. Standardization does help to streamline the onsite inspection process and is often an end goal for many of our Systems Inspection Option customers.

Our system laboratories find that the System Inspection Option has many benefits that help them save time and money:

• Having one inspection window within a two-year accreditation cycle rather than multiple inspection windows by moving all of your laboratories to the same anniversary date
• Utilizing the same checklist edition for all your sites for each inspection, helping to level set the standards you are preparing against
• Reducing the number of inspections that your team needs to perform—resulting in a noticeable reduction in the time and number of your staff out on reciprocal inspections
  • Your system would only be required to assemble one reciprocal inspection team every 18 to 24 months

Yes, all laboratories in the system will have the same anniversary date. This ensures that all laboratories are inspected using the same checklist edition.

When initiating the System Inspection Option, anniversary dates for some laboratories may need to be moved which may require that some laboratories have two inspections within a shorter timeframe until the routine inspection cycle is established.

The CAP Inspection Specialist is responsible for organizing the call/site visit with key system personnel to gather details about the system to help with the inspection planning and logistics. Whenever possible, the same CAP Inspection Specialist will join the inspection team for inspector continuity. During the call/site visit, the laboratory system will be asked to provide a proposed inspection schedule that will be shared with the inspection team.

Generally, the system inspection begins at the main site where the inspection team discusses the plans for the inspection, then starts with a major document review on day one. On subsequent days, the team spreads out across the system to visit the other locations. Since the same policies and procedures, etc are shared across the system of laboratories, they are not re-inspected at each location. When possible, the inspection team will use the same inspector for each checklist across all sites. For large systems, it is common for multiple sites to be inspected each day and there may be more than one inspector covering each checklist. When this occurs, the inspectors are encouraged to keep in contact throughout the day to ensure consistency across the findings.

Each site will have its own summation conference at the end of the inspection. Upon completion of the system inspection, the inspection team delivers a global summation conference discussing their findings across the system.

A global summation conference is presented at the conclusion of the system inspection. The global summation will provide the system with an overview of the system’s best practices and areas where there are opportunities for further standardization and/or additional attention is needed to sustain compliance system-wide. The information presented at this conference may be used by system administrators to prioritize and focus work efforts especially for management and/or quality department staff. The global summation conference is in addition to the individual summation conferences presented at each site.

Your system would be asked to inspect a comparably sized system and may be asked to travel across the country to perform a reciprocal inspection. For example, five to seven laboratory systems typically require three to four days for inspecting with approximately 10 to 12 inspectors total.

Yes, a CAP staff inspection specialist participates as a member of the inspection team. CAP inspection specialists are medical technologists with an average of 30 years of laboratory medicine and laboratory management experience. The CAP inspection specialist assists with:

• Inspection logistics
• Resolving issues that arise onsite
• Assisting the team leader to ensure consistency in interpretations from site to site
• Preparing the global summation presentation

In addition, the inspection specialists are assigned a checklist to inspect.

We ask that laboratories apply to the System Inspection Option at least one year in advance of the requested anniversary date.

This will help the CAP:

• Assign a similarly sized inspection team for a true peer inspection. Currently, system inspections are assigned at least one year in advance.
• Move all laboratories to the same anniversary date. Depending on the anniversary dates of all laboratories involved, some laboratories may need to need to move their inspection ahead resulting in more than one inspection in the two-year accreditation cycle.

Yes, participants in the System Inspection Option are charged a one-time application fee in addition to a yearly system fee—above and beyond each laboratory’s individual accreditation fees—based on the number of laboratories in your system. The system fee offsets the inclusion of a CAP Inspection Specialist and the increased travel expenses associated with the option.

This fee is due with the submission of the System Inspection Application. Email accred@cap.org to request an estimate for the System Inspection Option.