CAP Inspections and the Resident

Hello, fellow blog readers! It’s about 4 weeks since we communicated last. Since my first half of the year was loaded with lighter CP rotations to allow me to complete interviews for two successive fellowships, this half of the year is surgpath heavy and so that’s why I took a short hiatus from posting.

Well, I have a 4 week reprieve before I have another surgpath rotation and I am on what we refer to as our “comprehensive CP” rotation. Basically, it’s a combination chemistry-microbiology rotation. Since both of those rotations don’t always have enough work to require a resident to remain at the hospital for the usual 8-5 schedule, we cover both rotations simultaneously. We also have 11 comp CP rotations throughout the 4 years at my new program which is quite a lot but after the initial 2 months of “wet lab” rotating through all the stations in the chemistry and microbiology labs, we have the flexibility to tailor our comp CP rotation. And so, right now, I write as I sit in a hotel in Baltimore about to meet for our third preparation meeting before my attending and I go inspect a new molecular genetic pathology laboratory for the College of American Pathologists tomorrow. Since this is this lab’s first inspection, unlike the usual CAP inspection, this one is announced – they know we are coming and can prepare for our visit. The two of us will complete the entire inspection; my program counts this as rotation duties even though I am off-campus.

This is the second CAP inspection that I’ve been asked to assist with since I transferred to my program as a PGY-3. I think it’s great that my program gives our residents this opportunity since as attendings (whether we are AP or CP), we will also have to either assist in or enforce adherence to CAP or other accreditation standards and supervise preparations for lab inspections every other year and self-inspections on the alternate off-years. At my program, residents assist in both the preparations for CAP and off-year inspections. I’ve said it before, but residency is the transition from passive learning to active learning where we should participate in the daily responsibilities that our attendings oversee and that we will have in the future.

So, this inspection will be much more work than when I inspected the chemistry and special chemistry sections with my last team. Since there are only two of us, we are responsible for splitting the duties for the lab director, general, common, and molecular pathology accreditation checklists. CAP suggests a “ROAD” approach: read (through their binders of policies, SOP’s, etc), observe (a sample from receipt in the lab and though processing and interpretation of results), ask (open ended questions), and discover.

Well, I guess it’s time for me to go inspect but before I leave, I’d like to encourage all trainees (residents and fellows) to apply to serve as a junior member on one of the CAP’s committees or councils. You need to be a junior member but membership is free as a resident. Each committee or council (that oversees multiple committees in a topic area) usually has one junior member on it, very rarely, two. I’m currently serving my second year as the junior member on the Council on Education and I can say it has been a very rewarding experience where I have met many role models who definitely take an interest in what I have to say about the trainee opinion and who also think of me when opportunities arise that they think might be good for me. You can access both the instructions to apply (which includes a list of the committees/councils with junior member positions opening up in 2016) and the junior member application here – you will need a letter of recommendation from your program director and email in your app before the deadline of March 31st. Good luck guys! If you have any questions, feel free to email me.


-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

2 thoughts on “CAP Inspections and the Resident”

  1. Hi Dr. Chung,

    I am interested in your experiences as a CAP inspector. What were the most common citations that you’ve noticed? Also, did CAP tell the inspectors to focus on any area specifically?

  2. Hi Gia,

    Actually the places I helped to inspect were pretty good and had no more than one citation at most. I was a team member and not team leader so I was not the one who communicated with CAP so I don’t know if the team leaders were told to focus on specific areas or not. I know that I was not asked to focus on any area specifically by my team leaders. However, if the labs had any previous citations, I did make sure to check to see if they had addressed those issues cited the last time first. The CAP checklists are a good way (clearly and simply written) for both the lab managers, etc to know what they are supposed to do and what they may be inspected for and for the inspectors to follow when inspecting. I suppose if they are not clear, the lab manager could always call up CAP for clarification when making sure they are inspection-ready. Hope this helps and answers you questions.

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