From the President’s Desk: All systems go, and those who make it so, 12/13

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Gene N. Herbek, MD

December 2013—Some nonpathologists attribute our ability to negotiate the cutting edge of science and medicine to the tools we use. I’m not saying that tools aren’t important, but we know better. Our ability to navigate today’s volatile waters is the product of an affinity for quality and an inclination for systems-based thinking. First we get it right. Then we get it out.

Dr. Herbek

Given that context, the fact that 40 percent of actively practicing members volunteer for the CAP in one capacity or another speaks for itself. Among other things, it means that renowned experts have developed CAP programs and publications to promote and ensure excellence in laboratory testing. Those same experts gladly collaborate in low-profile roles, such as membership on inspection teams coordinated by the Laboratory Accreditation Program (LAP) and other CAP accreditation programs.

Our outsized ability to move medicine forward is grounded in a traditional commitment to quality assurance and quality improvement. The CAP leadership has long appreciated this; the Commission on Laboratory Inspection and Accreditation was established in 1962. Dennis B. Dorsey, MD, who would be CAP president from 1975–1977, sat down and wrote the first inspection checklist two years later, and the first accreditation certificate was issued 50 years ago next month.

Stories around development of CAP accreditation feature many pathologists who stepped up and put their heads together to figure out what quality concerns were most urgent and how to address them most effectively. The accreditation program as we know it today is a fine proof of concept: Volunteers and staff completed 2,813 inspections in the first eight months of 2013 and pathologists led the majority of those teams.

As of Oct. 1, 2013, 2,389 CAP members and 134 junior members had inspected for CAP accreditation programs within the past two years. A snapshot of metrics on that date shows that CAP has accredited 7,640 laboratories/biorepositories in its programs: 7,212 (LAP), 333 (reproductive), 39 (forensic drug testing), 22 (biorepository), and 34 (CAP 15189 for quality management and technical competency under ISO 15189).

Accreditation inspections are a peer-to-peer experience; members often say they learned as much when acting as inspectors as when inspected. This is our professional context, where we collaborate freely and share what we learn in the interest of patient safety.

The 21 LAP checklists reflect observations of inspectors who are qualified to recognize early signs of potential deficiencies. In some instances, our inspectors have noticed little gaps in documentation and other small oversights that suggest staffing pressures—an observation that may carry more weight with administrators when it comes from an objective third party.

The CAP’s accreditation program is framed on precision. Comments from inspections inform checklist reviews conducted by experts on our scientific resource committees, which further refine the requirements for optimal relevance and specificity. The LAP revises and republishes most checklists annually because they are both tools for evaluation and blueprints for quality. This translates to reliable guidance that keeps pace with rapidly evolving changes in our discipline and reflects awareness of challenges that new technologies—however welcome—can present.

While some inspectors are invited to join a particular inspection team because their subspecialty expertise is needed for a given site visit, inspector training is about much more than subject matter. Our inspectors learn how to ask a question for best effect and appreciate subtle cues. The result is a more efficient, thorough inspection where everyone learns.

While the CAP program is not the only accreditation resource that meets regulatory requirements, the precision of CAP requirements and its peer-to-peer, interactive nature have enabled us to create a reliable, systematic framework for quality improvement that only a pathologist-driven program can provide. When that peer-education mindset is inculcated and even celebrated in our laboratories, it becomes a gift that keeps on giving.

Participating on an inspection team does take time, and there is no denying the shortage of time in today’s laboratories, but there are undeniable professional and personal benefits to taking a step back and seeing how other laboratories juggle the same pressures. Peer-to-peer evaluation allows us to see ourselves as others might see us and reveals new ways to think about our work.

Laboratory accreditation and Surveys, which we talked about last month, are our best-known quality management programs, but there is much more on the menu. We have space this month to quickly mention just three more: Q-Probes, Q-Tracks, and the Sample Exchange Registry for Alternative Assessment. Taken together, they speak volumes about the CAP, but there is more to be said and I hope to return to this topic in the future.

Q-Probes and Q-Tracks, led by the Quality Practices Committee, enable laboratory staff members to set pre- and postanalytic performance goals and realistic benchmarks to track their progress. Peter Howanitz, MD, vice chair and clinical laboratory director of the Department of Pathology at SUNY Downstate Medical Center, came up with the concept 25 years ago. He remains intimately involved in its continuing success and many educational spinoffs. More than 15,000 anatomic and 42,000 clinical pathology participants have contributed to the robust database these programs have enabled. Q-Probes and Q-Tracks studies have been the basis of 130 papers in the Archives of Pathology & Laboratory Medicine and 39 papers in other peer-reviewed publications.

Finally, a few words on a relatively new and inspired notion that is moving our specialty forward from the ground up: the CAP Sample Exchange Registry for Alternative Assessment. Founded in 2007 as a resource for laboratories doing highly esoteric testing for which no PT was then available, the registry expanded in 2010 to accommodate any clinical laboratory providing a test for which there is no PT. Laboratory teams seeking alternative assessment contact the CAP. When three or more laboratories request a sample exchange for the same analyte or marker, we contact each with instructions to submit materials. The CAP anonymizes and distributes the samples within the group and the laboratories submit their results to the CAP. Each participant receives a report of its own results and a summary of aggregate anonymized findings—all at no cost.

The pathologist most closely identified with the registry was Jeffrey A. Kant, MD, PhD, a recipient of the CAP Lifetime Achievement Award and vice chair of the CAP Council on Scientific Affairs. Dr. Kant, a professor of pathology and human genetics at the University of Pittsburgh Medical Center, as well as a founder and the first elected president of the Association for Molecular Pathology, died of cancer in 2012. It was Dr. Kant’s intellectual curiosity, generosity, and well-appreciated ability to persuade that brought sample exchange to our armamentarium of programs and tools that enable us to drive progress in pathology from the ground up.

CAP quality improvement programs inculcate and celebrate the peer-to-peer mindset that has characterized our earliest initiatives and continues to inspire services that further patient safety and professional satisfaction. Becoming a CAP inspector confers membership on one of the best teams you can join, an affiliation that promotes excellence in countless ways, and in the process, enables us to take greater professional satisfaction in everything we do.
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Dr. Herbek welcomes communication from CAP members. Send your letters to him at president@cap.org.