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Laboratory accreditation program 2016 checklists: Less legwork, more clarity seen in personnel changes

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Anne Paxton

September 2016—For the CAP Laboratory Accreditation Program, inspection checklist requirements covering personnel are a perennial concern. They are the leading source of disparities between the findings of the program’s inspectors and inspection audits done by the Centers for Medicare and Medicaid Services. Personnel is also high on the list of questions asked of Laboratory Accreditation Program staff. “Personnel is a hot topic for the College,” says CAP Checklists Committee chair William W. West, MD.

Dr. West

Dr. West

Another round of revisions to the personnel checklist requirements may seem as routine as clockwork. But the 2016 edition of the checklists, released in August, “has the most significant personnel changes in several years,” says Dr. West, who is a pathologist at Physicians Laboratory, PC, in Omaha, Neb. The 2016 personnel checklist changes are, in part, the result of a Commission on Laboratory Accreditation decision to form a personnel workgroup to consider revising the laboratory personnel roster to help respond to the inspection disparities. “The College really seems to have gone out of its way this year to help tackle this complex area,” Dr. West says.
Members of the Checklists Committee believe the 2016 edition of the checklists will streamline inspections and pull more labs into compliance with CLIA personnel regulations, while relieving a major headache of labs by allowing independent verification of credentials to replace firsthand collection of documents.

Foremost among the changes: a new checklist requirement for the Personnel Evaluation Roster to ensure that the roster is current, accurate, and audited at least annually by the laboratory; added information on the qualifications and responsibilities of supervisors and consultants; and provisions for primary source verification reports, long sought by the CAP and recently approved by the CMS.

Getting on track with the CMS expectations was one goal of the 2016 changes because the number of discrepancies between the CAP inspections and CMS inspections on personnel records is a persistent issue, explains Gerald Hoeltge, MD, checklist commissioner and a member of the CAP Council on Laboratory Accreditation. “Disparities in personnel findings are the big problem area year after year after year,” he says.

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