What CAP Accredited Labs Need to Know Now About Online Deficiency Response

• CAP Accreditation

Julie McDowell:

The CAP's Accreditation Services is launching its Online Deficiency Response on December 20th. This will impact the way the CAP's accreditation customers send the necessary documentation for any deficiency cited during their inspection. In this CAPcast, Amy Daniels, the CAP's Technical Director of Accreditation Services, describes the new process for responding to deficiencies and how it impacts laboratories during the transition to the new process. Hi, Amy. Let's start off with an explanation from you about this new Online Deficiency Response.

Amy Daniels:

Online Deficiency Response is a digital platform to allow laboratories to submit electronic response and document submission to the CAP for review after a CAP inspection. This project was developed in response to customer requests for electronic document submission.

Julie McDowell:

And how will this Online Deficiency Response benefit laboratories?

Amy Daniels:

The Online Deficiency Response will benefit laboratories because it includes the ability to view deficiencies online and enter their response to a specific deficiency, and upload the supporting documentation. Additionally, if a laboratory would like to start the process immediately after a CAP inspection, they could elect to enter the deficiencies from the Inspector Summation Report and start the process of responding. If the laboratory prefers to let the CAP enter the deficiencies, the laboratory will receive an electronic notification when the deficiencies are ready for their response. This will occur approximately three days after the Inspector Summation Report is received by the CAP.

The new process will allow the laboratory to attach any modified policies, procedures, or records for CAP to review in response to a deficiency. The biggest advantage is the laboratory has the full 30 days to submit responses, and no longer has to account for printing and mailing time to CAP.

Julie McDowell:

What can a laboratory expect when using the Online Deficiency Response? Can you talk a little bit about some of the features and who can enter the information?

Amy Daniels:

Sure. Permissions to enter and submit are actually assigned by the Laboratory Site Administrator. The laboratory will be able to decide who can enter responses and attach supporting documentation. For example, you could assign any chemistry deficiencies to the Chemistry Supervisor, and they will be able to enter the response and attach the needed supporting documents, such as a revised procedure. The Laboratory Director must review, approve, and sign the laboratory's responses and supporting documentation to be submitted to the CAP.

Julie McDowell:

Now, do all laboratories have to use this or can they still submit documentation as they have been doing?

Amy Daniels:

This project will be implemented on December 20th, and any laboratory inspected after that timeframe will need to submit the responses and supporting documentation through this new system. We have included instructions on the CAP website to assist with this new process, and we're really hoping that our customers see the benefits and will want to use the new Online Deficiency Response.

Julie McDowell:

Finally, Amy, does this process bring any implications for inspectors?

Amy Daniels:

We are encouraging our inspectors to return the Inspector Summation Report by fax or email, so that our laboratories can begin their response process as soon as possible. We've also updated our instructions that our inspectors leave for the laboratory.

Julie McDowell:

Thank you, Amy. For more information on this new CAP Accreditation Services Online Deficiency Response, please visit the Accreditation section of cap.org.

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