Re: CAP Inspection

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From:Lee & Peggy Wenk <>
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Hi -

1. NSH has a guide for writing procedures in NCCLS format, with
histology examples. It's free to NSH members. (there might
be some shipping charges, though.

NSH can be contacted at 301-262-6221

2. We just had our inspection end of January. They went strictly
by the questions in the sections. Just make certain you have
documentation for EVERYTHING. Saying "yes we do that" doesn't
count unless there is paperwork or computer files to back up
your statement.

3. Any chance this is your lab's first experience with CAP?
If you've been through a CAP inspection before, then there is 
nothing new this year than there was in the last 2 years. If 
you've never been through one before, then you probably need 
lots of suggestion, but I don't really know where to begin. 

I would say QC and QI are very big. Make certain that you
are documenting all the QC you do, and then document that
you review your QC periodically (quarterly, semi-annually,
annually, whatever you have set up). Document the patterns
that were found, document the changes you made and the
training that you did so everyone knew about the changes and
how to do them. Then document that you went back and examined 
the changes some time later, and document that they worked or 
didn't work. If they didn't work, document this, and start
all over again making changes.

Another hint is to take the copy of the questions in Section 1
and Section 8, go through them yourself, and answer them
yes or no. Work on the no's to make them yeses. For each 
question, write in the margins where the documentation can 
be found. This helps when they ask the question, and you can't 
remember if it's in the Safety Manual of the hospital or the
Department's Chemical Hygiene Plan.

Another hint is to get the pathology residents, if you
have them, to do a mock inspection of the lab. Make them
pretend to be the inspectors, and ask all the questions.
It will give you experience finding the examples and
answering the questions. It will give them experience
as future inspectors. If you don't have residents,
then pair up with another supervisor, and inspect each
other's labs. This will give the supervisors experience
as future inspectors.

If you don't have your own copy of these sections, you can
go to the CAP web site, and print them out. Look under
Highlights for CAP checklists.

Good luck.

Peggy A. Wenk
William Beaumont Hospital
Royal Oak, MI 48073 wrote:
> Hi All
> I'm currently preparing for CAP inspection and am wondering if anyone has a
> good easy to use reference for writing procedures in NCCLS format?
> Has anyone recently been inspected? do you have any advice or suggestions to
> share? especially for new things? (we don't do immuno or EM, just routine
> surgical pathology)
> Thanks in advance.
> Nancy Adams

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