Whether your laboratory is accredited by CAP, COLA, JCAHO, or simply adheres to local state and federal CLIA regulations, all laboratories are subject to regular inspections from their accrediting agencies. Normally the thought of an inspection places staff into panic or hiding mode (“Whew, glad I’ll be off that week!”), but if you prepare ahead of time, the inspection process can be an extremely valuable tool to access the overall quality of your laboratory program. Over the next 3 blog posts we’ll review tips on 1) how to prepare before your inspection, 2) what to expect during the inspection itself, and 3) how to address any deficiencies identified by the inspection team.
Part One: The Inspectors Are Coming!
Know the Regulations. As technology evolves and new laboratory methodology is introduced, the requirements for your respective regulatory agencies will be updated as well. Know what version of your checklists or standards you will be getting inspected on, and ensure all staff are familiar with any updates and changes. By engaging all staff in the inspection process from lab assistants up through management, everyone will be aware of what the requirements are and can actively participate to ensure the lab is meeting those requirements.
Focus on Previous Citations. Your inspectors will have access to your previous inspection results, and will be following up on any citations. Ensure that the corrective actions and preventive actions you said you were going to implement have actually gone into effect. For any procedural changes, have documentation (Read & Understand) ready to show that all staff were made aware of and have been trained on the changes. Make sure that those corrections have been sustained and are effective at addressing the noted citation. It’s great to add on new forms to document instrument maintenance – but not if your staff doesn’t have the time to complete them. Again, engage your staff to see what is working, and what needs to be reevaluated.
What is New? New regulatory requirements, new staffing, new instruments, new testing methodologies… These are all key areas that the inspectors will focus on. Have you kept current with your regulatory updates and implemented any necessary changes to address the new requirements? Do you have documented training and competency for each new staff member for each task they are performing? For new instruments, ensure they have been fully validated and correlated to similar instruments prior to being placed into use for patient testing. When adding on new tests, ensure you have a full validation summary with medical director approval and sign off, and that your testing activity menu has been updated as well.
Have a Plan. Depending upon the size and scope of your laboratory, there can be a lot to cover for your inspection preparations. If you wait until your inspection window opens to start getting ready, things will be overlooked or simple “quick fixes” will be implemented instead of finding a long term sustainable solution to any potential issues. Instead, schedule tasks throughout the year to continually review your quality assurance program. Ask management to review 3 – 5 SOPs each month for content (does SOP match the current manufacturer package insert, does SOP match current practice in use), rather than a mass annual sign off. Perform quarterly reviews of your maintenance documentation to ensure all logs have been filled out completely with corrective action documented when appropriate. Utilize calendar reminders to track proficiency testing sample results, and ensure proper follow-up for any non-satisfactory results.
Perform Meaningful Self-Audits. For most regulatory agencies, performing self-audits on your non-inspection years is a requirement. Make this task meaningful by using a fresh set of eyes to review your documents. Ask the hematology staff to inspect the chemistry department; chemistry to inspect urinalysis; urinalysis to inspect microbiology…. You don’t need to understand how to actually perform a specific weekly maintenance task on a particular instrument; you just need to ensure that all those weekly tasks have been documented every 7 days (or less). You don’t need to understand what reagent ‘XYZ’ is used for, you just need to ensure that the vial is properly labeled with an open and expiration date, and that it is not currently expired and still being used. Self-audits should not be punitive; they are meant to catch things that you may be taking for granted are compliant, when in fact they truly are not.
Stay tuned for part 2 coming out next month, where we’ll discuss the inspection process itself and what to expect from the inspection team.
-Kyle Nevins, MS, MLS(ASCP)CM is one of ASCP’s 2018 Top 5 in the 40 Under Forty recognition program. She has worked in the medical laboratory profession for over 18 years. In her current position, she transitions between performing laboratory audits across the entire Northwell Health System on Long Island, NY, consulting for at-risk laboratories outside of Northwell Health, bringing laboratories up to regulatory standards, and acting as supervisor and mentor in labs with management gaps.
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