CAP, or the College of American Pathologists, is an accrediting body for laboratories. Their inspections are designed to improve laboratory quality by making sure proper safety and documentation procedures are followed. If your lab is CAP accredited, you’re likely familiar with the stress of preparing for a CAP inspection. CAP offers checklists to prepare thoroughly for inspection, but these are some of the common issues that histologists recommend double checking before inspection.
Temperature and Humidity
Make sure that you are keeping records of both the temperature and the humidity in your lab. Humidity can have an effect on staining; the more water there is in the air the more water there is going to be in your stain line. Showing documentation is one of the biggest things that CAP looks for. Document the changing of your filters. If you’re unsure of what temperature/humidity range is acceptable, look at the manuals for your instruments. Your embedding machine and your cryostat manual will most likely give you a required humidity range. When recording temperatures, be mindful of how often you’re recording them. If you are a lab that doesn’t have staff on the weekends, consider enlisting another department to come up and record temperatures.
Make sure you have procedure that addresses prevention of cross contamination in each station. For example, grossing cross contamination prevention should include how to avoid carryover between specimens; your microtomy procedure should state cleaning the waterbath between blocks. Many labs will have these cross contamination policies within the policies for each specific station, as opposed to one separate policy covering cross contamination as a whole. This is generally accepted, as long as you are able to point to where each item is covered. If you have the time and want to create a separate policy for all cross contamination in the lab that is great too.
Documentation on Resolving Issues
Make sure that you have quality control records, and a quality management program in place. Make sure that feedback is documented with the action taken to correct the issues. Make sure that validation and calibration is documented on all equipment.
· Make sure that there are labels on all of your reagents as well as expiration dates.
· Competency for high complexity testing personnel has to be done yearly.
Learn more about preparing for CAP Inspection with one of NSH’s CAP webinars, including CAP Inspection, Now What?, one of the webinars included in NSH’s new webinar bundle, 4 for $40.