Our laboratories at U.Va. were up for their bi-annual CAP inspection and the team showed up this Monday. Although the exact time of arrival is not fully known until they show up on your doorstep, we knew it was getting close, as we had been told they'd be here before the end of the year.
Although some may view these inspections with a sense of dread, and I admit that I did as well when I first took over as a director in our department, I've come to find them enlightening and actually enjoyable experiences. In fact, I've come to believe that of all the CAP's miriad activities, many of which I find to be of dubious value as my previous blogs will attest, I think the inspection program is their most valuable asset.
I also admit that my now enjoyment of these reviews is due in large part to the fact that we are blessed at U.Va. with excellent hospital staff and a faculty QA officer who make this process almost transparent for the rest of us. Once again the process was completely benign and our multi-site AP and CP labs received only a handful of easily correctable Phase 2 violations and no Phase 1 problems. As the chief of the inspection team joked at the closing session, we have to find some Phase 2's or the CAP won't reimburse our airfares! Virtually all of the Phase 2's were corrected on site before the inspectors left.
So why have I come to really value and even enjoy these inspections?
Although some of the checklist items certainly could be considered "picky," most are valid and following them results in improved patient care, which is after all why we're clinicians.
These reviews are, or are meant to be, non-confrontational and supportive rather than combative. The inspectors are our colleagues and we all have the same goals.
The inspection team almost invariably asks if there are issues with the local hospital administration for which they can be supportive. This has been very valuable to us in the past when we needed more space for laboratory functions. Our administrations, present at the closing session, were told in forceful terms in those instances that our space WAS inadequate, echoing our concerns and aiding in our obtaining additional space.
A positive CAP inspection puts pathology laboratories on a sound footing during JCAHO hospital reviews. In the past JCAHO reviewers virtually never even visited pathology laboratories when they had a CAP accreditation. They do now occasionally make directed reviews, often of the blood bank or other high profile areas, but for the most part we are out of their "crosshairs" thanks to a solid CAP assessment; and if they do visit, following CAP guidelines puts us in an excellent position. This is comforting because, unlike the CAP reviews, those guys DO make me a little nervous!
Finally, the inspection process is an excellent learning experience, both for the inspectees and, especially, for the inspectors. Many of my colleagues at U.Va. have participated in and headed inspection teams at other hospitals and invariably they have returned with new ideas, protocols, checklists, etc. that they found helpful for us during their inspection. This sort of "cross pollination" may well be the best feature of the inspection process.