CAP Webinar: Improve Your Quality with CAP Inspector Knowledge and Deficiency Data

 Webinar named “Improve Your Quality with CAP Inspector Knowledge and Deficiency Data” was organized by College of American Pathologists (CAP) on 7^th Jun 2022. Dr. Gregory Gagnon was the guest speaker.  His talk aimed to review the most cited deficiencies, improvement of laboratory process and discussion of the latest CAP tools/resources.

Firstly, Dr. Gagnon mentioned the top 10 deficiencies and then explained one by one. The following table showed those deficiencies and some of them were selected in this summary.

For competency assessment, the first year of an individual’s duties that his/her competency must be assessed at least semiannually and annually thereafter. The common deficiency is missing all 6 elements of competency.

1.          Direct observation of routine patient testing

2.          Monitoring the recording and reporting of test results

3.          Review of intermediate test results, records, and proficiency testing results

4.          Direct observation of instrument maintenance and function checks

5.          Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external proficiency testing samples

6.          Assessment of problem-solving skills

For instrument/equipment review, laboratory director or designee should review instrument/equipment maintenance and function check records at least monthly.

For proficiency testing evaluation, it needs ongoing evaluation of PT/EQA and alternative assessment results with appropriate corrective action taken for each unacceptable result. Major categories of investigation include Clerical, Analytical, Procedural, Specimen handling and PT material.

For temperature checks, it requested to check and record each day of use for all temperature-dependent equipment and environments using a calibrated thermometer. For non-working day, there must still be temperature monitoring such as using min/max thermometers.

New Lot/Shipment should be checked against previous reagent lots using reference materials.

Finally, Dr. Gregory Gagnon briefed CAP resources and newly expanded accreditation resources.  Lastly, he summarized the talk key points as follows.

Ÿ   Deficiencies can be opportunities for education and improvement.

Ÿ   If it is not documented, it didn’t happen.

Ÿ   Keep materials updated.

Ÿ   Ensure the staff have access to education and information.

Reference:

CAP - https://www.cap.org/

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