NOTE: You must complete this activity and the assessment questions to fulfill the training requirement.
The purpose of this activity is to provide you with the tools and techniques to be a successful inspection team leader as you select the appropriate team members, evaluate the laboratory director’s involvement in the laboratory’s culture of quality and safety, keep the team on track, and help resolve problems. It also provides inspection or auditing techniques, which will assist you in gathering the appropriate information to determine if your findings support compliance with the requirements. This activity is appropriate for new as well as experienced team leaders and team members.
After completing this activity, you should be able to:
- Use the information included in the Inspector's Inspection Packet to make decisions including determining team size and selecting appropriate team members.
- Effectively apply time management strategies to facilitate the inspection process.
- Evaluate compliance with the requirements for the director's role and responsibilities.
- Inform supervisors laboratory personnel of potential deficiencies as the deficiencies are identified (prior to Summation).
- Based on the information gathered during the inspection, cite deficiencies when the intent of the requirements is not met.
- Provide recommendations in compliant situations to promote process improvements.
- Ensure that recommendations are not provided in lieu of citing deficiencies in situations that are not compliant with accreditation requirements.
- Apply appropriate Lab General requirements.
- Ensure consistent interpretation of common checklist items (eg, QM, PT, QC, patient safety, method specifications, personnel/competency, safety, computers, reports).
- Apply the practice of corrected on-site versus removing deficiencies appropriately.
- Compare findings related to requirements common to all checklists to uncover systemic problems.
- Recognize situations which have caused or could cause serious immediate harm (immediate jeopardy) to patient or staff and act accordingly (eg, contact the CAP).
- Complete the pink deficiency ISR pages with sufficient detail to clearly describe the noncompliance.
- Recognize the purpose and importance of the Presummation and Summation Conferences.
- Complete ISR Part A (overall quality of the laboratory services) with sufficient detail to ensure that the comments support and supplement the deficiencies cited in Part B.
- Recognize the Commission on Laboratory Accreditation (CLA) policies that relate to the conduct of on-site inspections.
- Be familiar with the purpose and use of the checklists.
Accreditation: The College of American Pathologists (CAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME Category 1: The College of American Pathologists designates this internet enduring material educational activity for a
maximum of 5
AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CE (Continuing Education for non-physicians): The CAP designates this educational activity for a maximum of 5 credit(s) of continuing education. Participants should claim only the credit commensurate with the extent of their participation in the activity.
This activity is approved for continuing education credit in the states of California and Florida.
The American Society for Clinical Pathology (ASCP) Board of Certification (BOC) Certification Maintenance Program (CMP) accepts this activity to meet the continuing education requirements.
You must answer the assessment questions and complete the evaluation to claim credit and print your certificate.
Pop-up blockers must be turned off.
CAP Learning has recognized that some Veteran’s Administration, US Government, and military participants may have difficulty accessing the online assessment portion of this activity. If you experience difficulty or have any questions, please contact a representative of the CAP Learning Division at 800-323-4040 option 1 or firstname.lastname@example.org.
This activity and evaluation are available June 30, 2021, and expire July 19, 2021, at 12:00 AM (ET). You must claim credit by this date and time.