Switching to CAP

[Doug@SJL]

Hi to all,

I've just recently found this site and really have gained a lot from it. The hospital lab that I work at is switching from JC accreditation to CAP. Our first CAP visit will be sometime in the fall of 2009. I'm the blood bank supervisor and have noticed some differences in various aspects of the two. My question is if anyone has recently switched like this and would offer any pointers or if any are CAP now and would offer advice? We are a small facility (89 beds) but have a busy transfusion service (for the size of the facility) because of 2 cardiothoracic surgeons, a large (once again for the size of the hospital) oncology load, an orthopedic group, and are starting to increase labor and delivery. Any help would be of great value and thanks before hand for any ideas.

Doug

[LAS]

Start with the CAP BB checklist. It will guide you through it for the most part. When I inheritied the BB dept at my lab, the first thing I did (even though there was no inspection looming) was to review the checklist. If you are unsure about a standard or any commentary included with a standard, you can contact CAP and they will clarify it for you. Retain any info you get from them so as to show an inspector if you need to. Good luck!

[NedB]

Welcome to CAP. I've dealt with a lot of inspecting agencies over the years and CAP is by far the best. But then it is a peer review process. At some point you will inspect someone else. The CAP questions are all you really need, but don't forget the general lab questions - you are responsible for those too. Also, some the Transfusion Medicine questions sound like general lab, but you ought to know how your supervisor would answer the question. One that comes to mind is about qualifications of suppliers. The lab director needs to have a statement in the lab's SOP about suppliers and approval; and you should know what that response is. Same goes for the Disaster Plan and especially the Quality Assurance Plan. It's OK to use the general lab's as long as the details peculiar to the Blood Bank are noted (acceptable temperatures of 1 to 6C, monitoring and recording temperatures during power or recording failure). I would suggest you write the location of the form or the procedure which covers the answer to each question. CAP now comes unannounced, so you plus someone else should know all these answers. Writing them should put you on the same page. Good Luck.

[Doug@SJL]

Thanks LAS and NedB for the replies.

[Karen Olsen]

I have been through many CAP inspections and have had conducted several as well. It is a great opportunity to exchange knowledge and information. As stated above - if you are compliant with each of the CAP standards for BB and lab general - you will have no problems. I am also responsible for the BB at a sister facility which is JC certified. I find CAP to be much more user friendly than JC. Maybe just because I am more familiar with it, but it just seems so much more straight forward to me than JC. Also, JC has been big on tracers for some time and now CAP is joining in and recommending that inspectors use this method to inspect. In the past CAP spent a lot of time looking at P&P's but not necessarily correlating it to the fact that you actually do what you say you do.

Good Luck!