New push to strengthen interim self-inspections

Anne Ford

January 2013—Unless you have a full-time custodial staff at home, you have the same small annoyances around the house that nearly everyone has. Perhaps it’s a patchy paint job in the upstairs hallway. A closet light that burned out long ago. A dishwasher that periodically leaks. All things that visitors might not know about, but you do. And all things you’ve likely learned to live with in lieu of fixing.

Left undone, some little jobs like those don’t have much of an effect beyond the aesthetic. But some—like a dead smoke-detector battery or a broken porch step—can have dangerous consequences. That goes double, of course, in the laboratory, where even a mildly malfunctioning piece of equipment can result in grave hazards down the line.

Unfortunately, despite one’s best intentions, it’s just as easy to get desensitized to potential risks in the laboratory as it is in the home. “Sometimes when you go to the same place every day, you may not see things,” says Kailash Sharma, MD, pathology department chief and laboratory director at University Hospital, Augusta, Ga., and chair of the CAP’s Inspection Process Committee.

That’s why CAP-accredited laboratories perform self-inspections: to guard against the all-too-human tendency to overlook or become desensitized to potentially troublesome issues. The College, of course, has long required its accredited laboratories to perform and document an annual internal inspection between biennial CAP inspections. The aim of a self-inspection isn’t just to “keep a list in the file for CAP inspectors to come and look at,” as Dr. Sharma says; it’s to identify and remedy potential noncompliances that might result in deficiencies during the external inspection.

As of October, the Inspection Process Committee and the Continuous Compliance Committee have joined forces to encourage more CAP-accredited laboratories to ramp up their self-inspection efforts. “We have felt that the interim self-inspection isn’t really providing us with the kind of assurance we would like to see that laboratories are doing this well and documenting their compliance,” says John Olson, MD, PhD, professor of pathology at the University of Texas Health Science Center, San Antonio, and a member of the Continuous Compliance Committee.

“Now, it’s unfair to paint all laboratories that way,” he adds. “There certainly are many laboratories that do this extremely well. But we would like to increase the quality and the value of the self-inspection in all laboratories.”

Part of the issue, in Dr. Olson’s view, is that not all CAP inspectors thoroughly review the documentation of a laboratory’s self-inspection at the time of the external inspection. “I’ve been here at UHS for 14 years and have gone through seven inspections, and I don’t think there has been a single instance of an inspector requesting to see the results of our interim inspection,” he says. “I’m not criticizing the inspectors; I think it just has not been a habit to check. I have to admit that in the past, I have not been consistent about doing this as an inspector myself.”

Some inspectors may simply verify that the documentation of the self-inspection exists, rather than take the time to go over it in detail. Says Dr. Sharma: “I think there are probably some inspectors who do not look at it as deeply and ask questions about what you found, how many deficiencies you found, how you corrected them, and whether you have documented the corrections process. They may be looking at the list and saying ‘Okay, you corrected these things, let’s move on.’”

The Inspection Process Committee, Dr. Olson says, plans to examine the inspection checklist wording “to be sure that it’s good in this regard” and to “re-emphasize to inspection team leaders that reviewing self-inspection information at the time of the on-site inspection is something that we want to have done more faithfully.”

For laboratories, CAP inspector and former Continuous Compliance Committee chair Renee R. Ellerbroek, MD, a pathologist with Iowa Pathology Associates, Des Moines, has one major piece of advice: “Treat a self-inspection like a real event.”

That is, do everything in your power to make the self-inspection as much like a CAP inspection as possible. “Formalize the inspection procedure,” she says. “Put a date on the calendar.” And avoid the piecemeal approach. “I would definitely recommend performing the inspection at one time,” she says. “It’s tempting to say, ‘We’ll do a couple questions today and a few more tomorrow,’ just kind of folding it into the normal workload. If at all possible, say, ‘Today is inspection day.’”

Begin the self-inspection process, Dr. Ellerbroek urges, by reviewing the deficiencies cited in the last CAP inspection. “Look at these and reconcile them with your deficiency responses to see if you’re really doing what you told the CAP you were going to be doing,” she says. “If you’ve neglected these, and the deficiency is cited again at the next live inspection, it’s a good indication that a serious self-inspection was not performed.”

She speaks from experience. “As a regional commissioner, I reviewed deficiency responses,” she says. “If there were recurring deficiencies over multiple inspection events, it would tell me that the laboratory wasn’t looking at itself very objectively during the interim self-inspections.”