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Version no.10172022
 Guide to CAP Accreditation

Table of Contents

Laboratory Accreditation and the College of American Pathologists 3

Ten Steps to CAP Laboratory Accreditation 4

Things to Know for CAP Laboratory Accreditation 6

Application Process 8

Director Responsibilities 9

Laboratory Director Qualifications 10

Document Control System 12

Chemical Hygiene Plan 13

Laboratory Information Systems (LIS) 14

Test Menu Validation and Verification 16

Competency Assessment Program 18

Quality Management System (QMS) 20

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 Guide to CAP Accreditation

LABORATORY ACCREDITATION AND THE COLLEGE OF AMERICAN PATHOLOGISTS

About the CAP We are experts in laboratory accreditation because that is our exclusive focus.
Laboratory Our programs help laboratories stay current with the ever-evolving changes of
Accreditation laboratory medicine and technology, as well as the regulatory landscape through
Program the input of our pathologist members and laboratory professionals around the
world. As a result, CAP Accreditation is globally recognized as the most rigorous
choice to achieve and maintain regulatory compliance.

Our annually updated accreditation checklists provide a road map for running a
high-quality laboratory while simplifying the accreditation process. The checklists
are used by the laboratory to prepare for inspections and by the inspection team
as a guide to assess the overall quality of the laboratory and compliance with
CAP checklist requirements. CAP inspections are educational, not punitive. Our
unique, reciprocal, peer inspection model benefits both the laboratories being
inspected and the laboratories providing the inspection teams.

Only the CAP offers an engaging, dynamic, collaborative process that fosters an
environment of continuous improvement to ensure the highest quality patient
care.

What to expect by A laboratory inspection with a CAP-provided team occurs every two years. To
participating in the meet each laboratory’s unique needs, inspection methods may include in-person
CAP Laboratory
or virtual inspections, document review prior to or during the inspection, or some
Accreditation
Program? combination of these methods. In the years when an external inspection does
not occur, the laboratory performs a self-inspection using materials provided by
the CAP.

Prior to inspection, the laboratory is provided with customized checklists based

on the laboratory’s testing menu The inspection team will use the same
customized checklists during the inspection.

Following the completion of an inspection, the inspector will provide the

summary of inspection findings to the laboratory staff. The laboratory has 30
days to submit responses to identified deficiencies to the CAP. After
successfully meeting all the requirements, the laboratory is awarded a “CAP
Laboratory Accreditation” certificate and becomes part of an exclusive group of
nearly 8,000 laboratories worldwide that have met the highest standards of
excellence.

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 Guide to CAP Accreditation

TEN STEPS TO CAP LABORATORY ACCREDITATION

1 Request ▪ Fill out and submit the Request for Application* form at cap.org.
Application
*Note for International laboratories: you must be enrolled in CAP Proficiency
Testing (PT)/External Quality Assurance (EQA) for a minimum of six months
before requesting an application.

2 Review ▪ Check your email to access the link to the online application (look for “CAP
Welcome Kit Accreditation Application Available” in the email subject line).
▪ Review additional information enclosed with the application link on how to
get started with the accreditation process.
▪ Schedule an optional onboarding call with CAP staff who will guide you
through the next steps in the accreditation process and answer questions.

3 Complete ▪ Complete the accreditation application within 3 months from the day it
Application becomes available online**.
▪ Review the due date on the homepage after you log in.
▪ Monitor email reminders that the CAP will send out as the application due
date approaches.
▪ Work with the CAP staff on any follow-up questions during application
review.
**NEW – Laboratories now have the option to upload a preselected set of
documents for review by the inspectors ahead of the inspection date during their
application submission process.

4 Receive ▪ Receive customized checklists by mail and begin inspection preparation

Customized and/or
Checklists
▪ Download customized checklists online by logging into your account if you
prefer electronic checklists.

5 Schedule ▪ Look for a letter in the mail (sent to the accreditation contact from your
Inspection Date laboratory) announcing the inspection team leader’s name and organization.
▪ Schedule*** the inspection date with the inspection team leader (the team
leader will contact the laboratory director to set the inspection date).
▪ Prepare for the initial inspection that will take place within 6 months after the
submission of the online application.
***Note: After the first inspection, all subsequent routine inspections for the
Laboratory Accreditation Program are unannounced.
For international laboratories and specialty accreditation programs, subsequent
routine inspections are announced.
All inspections are performed within the 90-day period preceding the
anniversary date.

6 Host Inspection ▪ If the inspection is in-person, expect the arrival of the inspection team who
Day will conduct the inspection with the same customized checklists that you
received earlier.

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 Guide to CAP Accreditation

▪ Support the inspection team as needed or requested.

▪ Receive a copy of the summary report from the inspection team leader
(given to the laboratory director) during the summation conference.
▪ For inspections with advance document review, be sure to upload your
documents or share the guest access link to your document management
system (whichever the laboratory and inspector have agreed upon) by the
designated date so that the inspection can proceed smoothly
▪ For Virtual inspections, ensure that the videoconference link has been
distributed to everyone who will need to participate in the inspection.

7 Respond to ▪ Review the instructions for responding to deficiencies provided by the

Deficiencies inspection team.
Within 30 Days
▪ Submit all responses within 30 calendar days after the inspection date.

8 Support CAP ▪ Collaborate with the CAP technical specialist on any follow-up questions
Review of regarding submitted responses.
Responses
▪ Promptly respond to requests from the technical specialist to provide
additional documentation when needed to complete the review of deficiency
responses.
▪ Anticipate an accreditation decision within 75 days of the inspection date.

9 Receive ▪ Look for the laboratory’s Certificate of Accreditation by mail, to the attention
Certificate of of the laboratory director.
Accreditation
▪ Mark your calendar with anniversary date displayed on the certificate.

10 Perform Self- ▪ Receive materials from the CAP and conduct a self-inspection around the
Inspection and laboratory’s one-year anniversary date. Correct deficiencies identified
Maintain during the self-inspection and retain records of these activities.
Continuous
▪ Make changes in laboratory directorship, location, name/ownership, test
Compliance
menu, roles, and personnel by logging into e-LAB Solutions Suite at any
time.
▪ Enroll in or discontinue PT/EQA products when the test menu changes, if
needed, by contacting the CAP Customer Contact Center or visiting our
online store.
▪ Note that the accreditation cycle repeats every two years, starting with
completing the reapplication in Step 3, seven months prior to the two-year
anniversary date.

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THINGS TO KNOW FOR CAP LABORATORY ACCREDITATION

Eligibility The laboratory must have a qualified laboratory director, successfully

participate in the appropriate proficiency testing/external quality assurance,
and be performing patient testing.

Director The CAP requires specific qualifications for the laboratory director, the person
Qualifications responsible for operation of the laboratory. Qualifications of the director may
differ based on the type and complexity of the testing performed. A laboratory
director must have an MD, DO, DPM, PhD, and must have the experience
necessary to meet personnel requirements as determined by the CAP. Refer
to the Laboratory Director Qualifications chart below for more detail.

Laboratory CAP requires that all high complexity testing personnel have earned at least a
Personnel minimum of an associate degree in a laboratory science or medical technology
Qualifications
from an accredited institution. Personnel performing moderately complex
testing must have earned a least a high school diploma or equivalent.

The laboratory must retain records that all testing personnel have satisfactorily
completed initial training on all instruments/methods applicable to their
designated job.

Proficiency Testing Proficiency Testing (PT)/External Quality Assurance (EQA) is an

(PT)/External Quality interlaboratory peer program that compares a laboratory’s test results using
Assurance (EQA)
unknown specimens to results from other laboratories using the same or
similar methods. Laboratories subject to US regulations must enroll and
participate in a CAP-accepted PT program for all required analytes (see the
Master Activity Menu to determine which analytes require enrollment in PT).

For international laboratories, the laboratory must enroll in all available CAP
PT/EQA a minimum of six months prior to requesting CAP application.

This time frame enables the international laboratory to become familiar with
the requirements necessary to obtain permits and any other documents
needed to receive PT/EQA shipments.

Key Components To meet CAP Laboratory Accreditation requirements, the laboratory must have
the following key documents/processes:

• Quality Management System

• Chemical Hygiene Plan
• Document Control Process
• Competency Assessment Program
• Test Method Validation and Verification Records
• Laboratory Director Oversight Records
• Laboratory Information System (LIS) – if applicable

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Additional The following products and documents are available from the CAP to assist
Resources laboratories in the process of preparing for accreditation as part of the non-
refundable accreditation application fee:

• Focus on Compliance Webinars

• Online Inspector Training
• CAP Accreditation Checklists
• Laboratory Accreditation Manual
• Proficiency Testing (PT)/External Quality Assurance (EQA) Toolbox
• Standards for Laboratory Accreditation
• CAP Accreditation Resources Library

The following items are available for an additional fee:

• CAP Accreditation Readiness Assessment (CARA)
• Online Competency Assessment Program
• Q-Probes and Q-Tracks

Cost of Accreditation Annual accreditation fees are based on the institution’s laboratory sections, list
of testing performed (activity menu), organization structure, and complexity.

To receive an estimate of annual accreditation fees, complete and return the

Accreditation Fee Estimate Form available at cap.org.

International laboratories are required to pay for roundtrip, business-class

airfare for intercontinental travel by inspector(s). The number of inspectors
sent will be based on the volume and/or type of testing performed by the
laboratory. The CAP will pay for all hotel accommodations, meals, ground
transportation and in-country air travel. Inspections typically occur once every
two years.

In response to the global health emergency and associated travel restrictions,

the CAP has modified the laboratory inspection processes to allow international
inspections at laboratories not subject to the CLIA regulations to be virtual
instead of in-person. This is a temporary process implemented in response to
the global pandemic. Because the duration of the pandemic and associated
travel restrictions is unknown, we recommend that accredited international
laboratories continue to budget for their inspection expenses, including airfare
for US inspectors. International laboratories with a CLIA certificate may have
virtual inspections but will require an onsite visit to verify safety and facility
requirements using in-country or within region inspectors when possible and
practical.

Please note that accreditation fees do not include the cost of proficiency
testing/external quality assurance.

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APPLICATION PROCESS

Overview The application process involves two steps: 1) Request for application; and 2)
Completion of the online application in Organization Profile by logging into e-
LAB Solutions Suite on cap.org.

Request for Download the Accreditation Request for Application form at cap.org.
Application
• Complete the form
• Submit via email, mail or fax (information provided on form)
• Include the one-time, nonrefundable application fee
- Credit card
- Wire transfer
- Check

What’s Next? After the Request for Application is processed by the CAP, the laboratory will
receive an email notification with instructions for accessing the online
Organization Profile through the CAP’s online resource (e-LAB Solutions Suite).

Online Application Once all tasks are completed in the laboratory’s Organization Profile, click on
the “Application Complete” button.

For assistance, contact the Customer Contact Center at 001-847-832-7000 or

email [email protected].

The applications must be completed within three months of receipt by the

laboratory.

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DIRECTOR RESPONSIBILITIES

What are the The director of a CAP-accredited laboratory is responsible for ensuring ongoing
Director’s compliance with the Standards for Laboratory Accreditation and implementing
Responsibilities?
the requirements of the accreditation checklists. The director must have the
qualifications and authority to fulfill these responsibilities effectively.

Key Components An effective director ensures:

▪ The following components are defined, implemented, and

monitored:
– An effective quality management system.
– An adequate number of appropriately trained and qualified personnel.
– A safe laboratory environment.
▪ Availability of consultations for ordering appropriate tests and the
interpretation of the medical significance of laboratory data.
▪ Anatomic pathology services are provided by a qualified anatomic
pathologist.
▪ The ability to function effectively with applicable accrediting and
regulatory agencies, the medical community, patients, and
administrative officials.
▪ Educational programs, strategic planning, research, and
development appropriate for the laboratory and institution.
▪ Qualified section directors for all sections of the laboratory if the
laboratory director is not qualified to direct any of the individual
sections.
▪ If delegating activities to others, documentation specifying which
individuals are authorized to act on his/her behalf.
▪ A written policy or agreement defining involvement of the
laboratory director, including activities performed on-site and
through remote consultation, and periodic on-site visits if activities
are routinely conducted remote.

Who Is Responsible? The director of a CAP-accredited laboratory is responsible for ensuring ongoing
compliance with the Standards for Laboratory Accreditation and implementing
the requirements of the accreditation checklists.

Outcome of an Laboratory benefits include:

Effective Director
1. A culture committed to continuous improvement.
2. An involved director who serves as a mentor and promotes a culture of
quality.
3. A safe environment.
4. Ongoing compliance with the CAP requirements.
5. A testing environment always prepared for an inspection.

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LABORATORY DIRECTOR QUALIFICATIONS*

Laboratories subject to US regulations

High Complexity Testing 1. MD, DO, or DPM licensed to practice in the jurisdiction where the
laboratory is located (if required), and have one of the following:
- Certification in anatomic or clinical pathology, or both, by the
American Board of Pathology or American Osteopathic Board of
Pathology, or possess qualifications equivalent to those required
for certification**; or
- Have at least one year of laboratory training during medical
residency/fellowship; or
- Have at least two years of experience supervising high
complexity testing;
OR
2. Doctoral degree in a chemical, physical, biological, or clinical
laboratory science from an accredited institution, and have current
certification by a board approved by HHS***
Moderate Complexity 1. Qualified as in (1) above
Testing OR
- MD, DO, or DPM, licensed to practice in the jurisdiction where the
laboratory is located (if required) and have one of the following:
- At least 20 hours of continuing medical education credit hours in
laboratory medicine; or
- Equivalent training during medical residency/fellowship; or
- At least one year of experience supervising non-waived
laboratory testing
OR
2. Doctoral degree in a chemical, physical, biological, or clinical
laboratory science from an accredited institution with one of the
following:
- At least one year of experience supervising non-waived
laboratory testing; or
- Current certification by a board approved by HHS***
Provider Performed 1. MD or DO, or DPM, licensed to practice in the jurisdiction in which the
Microscopy Testing laboratory is located (if required)
Waived Testing 1. MD or DO, or DPM, licensed to practice in the jurisdiction in which the
laboratory is located (if required) OR
2. Doctoral degree in a chemical, physical, biological, or clinical
laboratory science from an accredited institution
Laboratories not subject to US regulations

All Testing Complexities 1. MD, DO licensed to practice in the jurisdiction where the laboratory is
located (if required) and have one of the following:
− Certification in anatomic or clinical pathology; or

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− At least one year of laboratory training during medical

residency/fellowship; or
− At least two years of experience supervising high complexity
testing
OR
2. Doctoral degree in a chemical, physical, biological, or clinical
laboratory science and have both of the following:
− At least two years of clinical laboratory training or experience
and
− Two years of laboratory experience directing or supervising high
complexity testing
Notes:

i. For laboratories subject to US regulations, additional qualifications for grandfathered individuals and
for the subspecialty of oral pathology may be found in the CLIA regulation 42CFR493.1443(b)(6).
ii. If more stringent state or local regulations are in place for laboratory director qualifications, including
requirements for licensure, they must be followed.
iii. A single individual may direct no more than five laboratories (not including laboratories that perform
only waived testing) and may not direct more laboratories than permitted by national, federal, state (or
provincial), or local law.

*Additional qualifications for laboratory directors are defined in the checklists for the following types of
testing or services:

• Qualifications for histocompatibility laboratory directors, including continuing clinical laboratory

education requirements, can be found in the Histocompatibility Checklist.
• For laboratories participating in the Reproductive Laboratory Accreditation Program, directors
of laboratories performing andrology testing must meet the requirements described above for
high complexity testing and have at least two years of experience in a laboratory performing
andrology procedures. Requirements for embryology laboratory directors are found in the
Reproductive Laboratory Medicine Checklist in RLM.10166.
• For laboratories participating in the Forensic Drug Testing Accreditation Program, specific
requirements for laboratory director/scientific director are found in the Forensic Drug Testing
Checklist.

** Individuals qualifying as board-eligible must supply a letter or other equivalent record from the board
with their eligibility status.

*** A list of boards approved by the CMS for doctoral scientists may be found at:
https://www.cms.gov/Regulations-and-
Guidance/Legislation/CLIA/Certification_Boards_Laboratory_Directors

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DOCUMENT CONTROL SYSTEM

What is Document Document control is the management of all paper or electronic documents,
Control? including policies, procedures, and forms. A written document control system
outlines how all documents are initiated or revised, approved, utilized, reviewed,
retained, and discontinued.

Every document within the laboratory must be:

▪ Current – have up-to-date review and reflect current practices.

▪ Accurate – only authorized revisions are made to documents, substantial
revisions are reviewed and approved before implementation, and revisions
are reflected on all copies of documents.
▪ Available – readily accessible to all staff utilizing them.

Key Components A laboratory’s document control system must ensure:

▪ All copies of policies, procedures, and forms are current.

▪ Personnel have read the policies and procedures relevant to their job
activities.
▪ Personnel are knowledgeable about the contents of procedure manuals
(including changes) and demonstrate proficiency relevant to the scope of
their testing activities.
▪ All policies and procedures have been authorized by the laboratory director
before implementation.
▪ Policies and procedures are reviewed at least every two years by the
laboratory director or designee.
▪ Discontinued policies and procedures are quarantined in a separate file for
a minimum of two years from the date of discontinuation (five years for
transfusion medicine).

Who is Responsible? The laboratory director who meets CAP director qualifications is responsible for
implementing and maintaining an effective document control program.

Outcome of an The laboratory will benefit by:

Effective System
▪ Ensuring on any given day practice matches policies and procedures.
▪ Promoting the use of only approved policies, procedures, and forms.
▪ Organizing procedures for ease of accessibility by testing personnel.
▪ Tracking the status of approvals and reviews to ensure they occur in a
timely manner in accordance with CAP requirements.
▪ Maintaining ongoing compliance with CAP requirements.

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CHEMICAL HYGIENE PLAN

What is a Chemical A Chemical Hygiene Plan (CHP) includes procedures to protect employees
Hygiene Plan? from the health hazards of chemicals and keep exposures below specified
limits. All personnel involved in the laboratory must receive training on the CHP
and understand how it applies to their role.

Key Components An effective CHP includes:

▪ Defined laboratory director responsibilities and the designation of a

chemical hygiene officer.
▪ Safety data sheets (SDS) for all hazardous chemicals used in the facility.
The SDS must be accessible for review by all laboratory employees during
every work shift.
▪ A training program on interpreting chemical labels and SDS, and the use of
proper protection for chemical handling and disposal.
▪ Proper labeling on all chemical containers.
▪ Informing all laboratory employees of the right to know the hazards
associated with their job.
▪ Evaluation of every chemical used in the laboratory for carcinogenic
potential, reproductive toxicity, and acute toxicity.
▪ Annual review of the effectiveness of the CHP to include review of all
incidents and occurrences of the past year.

Who is Responsible? The laboratory director is responsible for the CHP.

Outcome of an The laboratory will benefit by:

Effective System
▪ Increased employee safety and awareness.
▪ Reduction in laboratory accidents and improved spill responses.
▪ Safe and efficient organization for chemical storage.
▪ Ongoing compliance with CAP requirements.

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LABORATORY INFORMATION SYSTEMS (LIS)

What is a Laboratory Laboratory information systems (LIS) provide a database serving the
Information System? information needs of the laboratory by linking patient test results to the ordering
clinician/client, and to the patient’s medical record.

Overview Multiple types of LIS are available, including:

▪ Systems with a local host database (computer hardware and software on

site) where the laboratory is the only user.
▪ Systems with a host physically removed from the laboratory, where
multiple user laboratories may share the same database.
The Laboratory Accreditation Program does not consider the following types of
devices as an LIS:

▪ Small programmable technical computers or dedicated microprocessors

that are an integral part of an analytic instrument.
▪ Purchased software services used for quality assurance and data
analysis.
▪ Microcomputers used for word processing, spreadsheets, or other similar
single-user functions.

Key Components The laboratory must ensure the following:

▪ Computer facility and equipment with appropriate environmental controls

and safety elements.
▪ Written LIS policies and procedures with instructions for daily operations
appropriate to the level of use.
▪ Training for all users of the system relevant to the scope of their duties.
▪ Testing of the LIS for proper functioning at installation and when changes
are made.
▪ System security policies and practices for user authentication, user
authorization privileges, protection against unauthorized alterations, and
network security.
▪ Error detection and timely communication of patient data to the ordering
clinician/client.
▪ Validation of autoverification (if used) initially and when changes are
made to the system that can affect the autoverification logic.
Autoverification is a process where the LIS has defined parameters that
allow results to flow from an interfaced instrument to the medical record
without technical intervention or review. Defined system logic prevents the
release of test results not meeting the defined parameters or criteria.
▪ Accurate transmission of data across instrument interfaces and interfaces
with other computer systems (eg, middleware, hospital information
systems, and other output devices).
▪ Data retrieval and preservation for the required regulatory retention period
available, within a time frame consistent with patient care needs.

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Who is Responsible? The laboratory director is responsible for ensuring communication of laboratory
data.

The director may delegate some LIS-related functions to others and is

responsible for determining the qualifications of these individuals. It is the
director’s overall responsibility to ensure these functions are properly carried
out.

Outcome of an The laboratory benefits include:

Effective System
▪ Accurate and timely transmission of patient data.
▪ Effective presentation of patient data.
▪ Retention and retrieval of patient data consistent with regulatory
requirements.
▪ Improved efficiency and productivity in the laboratory.
▪ Ongoing compliance with CAP requirements.

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TEST METHOD VALIDATION AND VERIFICATION

What is Test Method Prior to clinical use of each test, the laboratory is required to establish or verify
Validation and Test the test method performance specifications to ensure that the test is adequate
Method Verification?
to meets clients’ needs.

Analytical test method verification is the process by which a laboratory

determines that an unmodified FDA-cleared or approved test performs
according to the specifications set forth by the manufacturer when used as
directed. For laboratories not subject to US regulations, this also includes
unmodified tests approved by an internationally recognized regulatory
authority (eg, the European Union's Conformité Européenne (CE) Marking).

Analytical test method validation is the process used to confirm with objective
evidence that a laboratory-developed test (LDT) or modified FDA-cleared or
approved test delivers reliable results for the intended application. For
laboratories not subject to US regulations, this also includes modified tests
approved by an internationally recognized regulatory authority (eg, the
European Union's Conformité Européenne (CE) Marking).

Overview The test method validation or verification process must include:

▪ Written procedures describing the validation or verification process

for new instruments and methods.
▪ Documentation of data collected in the testing environment where
the method will be implemented.
▪ Data obtained from studies performed by the manufacturer and from
published literature, as applicable.
▪ Written assessment of the validation or verification studies by the
laboratory with approval by the laboratory director or designee
meeting CAP director qualifications prior to initiation of patient
testing.

Key Components ▪ The type of method validation/verification required is dependent on

the type of testing as defined by the CAP.
▪ For waived testing, laboratories must follow manufacturer’s
instructions for introduction of the instrument or device and have
records that the test has been approved for use.
▪ For unmodified, nonwaived commercial assays, including FDA-
cleared or approved tests (and tests approved by an internationally
recognized regulatory authority for laboratories not subject to US
regulations), the laboratory must verify the following test method
performance specifications, as applicable:
- Analytical accuracy – closeness of agreement between a test result
and an accepted reference value.
- Analytical precision – reproducibility of a test result.
- Analytical interferences– ability of an analytic method to detect only

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the analyte it was designed to measure.

- Reportable range – interval of test results for which the laboratory
can establish or verify accuracy.
- Reference intervals – range of test values expected for a
designated population.
- All other characteristics required for test performance.
▪ For laboratory-developed tests (LDTs) and modified commercial
assays, the laboratory must establish all test method performance
specifications listed above, as well as the following, as applicable:
− Analytical sensitivity – lower detection limit.
− Analytical specificity – ability of a test to correctly identify or
quantify an entity in the presence of an interfering or cross-
reactive substance that may be expected to be present.
− Other performance characteristics required to ensure analytical
test performance – examples include specimen and reagent
stability, linearity, carryover, and cross-contamination.
− Clinical performance characteristics – includes statements about
a test’s sensitivity and specificity, and may include determining
predictive values for a relevant disease or condition, as
applicable, for LDTs.

Who is Responsible? The laboratory director or designee who meets CAP director qualifications is
responsible for ensuring each method performed is of sufficient scope and
scientifically valid. The director or designee documents final approval of the
validation or verification prior to the initiation of patient testing.

Outcome of an The laboratory benefits include:

Effective System
▪ Organized and clear evidence of test method validation and verification.
▪ Accurate patient test results when the new method is implemented.
▪ Ongoing compliance with CAP requirements.

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COMPETENCY ASSESSMENT PROGRAM

What is Competency A competency assessment program appraises an individual’s knowledge and

Assessment? mastery of skills needed to properly perform a specific job.

Key Components
Assessment of competency involves evaluation of the applicable elements of
competency by a qualified individual for each test system at the required
frequency.

Six Elements of ▪ Direct observations of test performance.

Competency ▪ Monitoring of test result reporting.
Assessment
▪ Review of quality control records, proficiency testing results, and
preventive maintenance records.
▪ Direct observation of instrument maintenance and function checks.
▪ Assessment of test performance by external proficiency testing or internal
blind testing samples.
▪ Evaluation of problem-solving skills.

System Components A laboratory must have a process ensuring:

▪ Competency assessment is performed at the required frequency:

− Nonwaived testing - at least semiannually during first year an
individual tests patient specimens, and annually thereafter.
− Waived testing - after an individual has performed assigned duties for
one year, and at least annually thereafter.
▪ All test systems used for patient testing are defined.
▪ Competency is assessed using the six elements of competency for each
test system:
− Nonwaived testing – requires assessment of all six elements, as
applicable to the duties performed.
− Waived testing – program selects which elements to assess.
▪ Records of personnel competency assessment are retained.

Who Can Assess Individuals assigned to assess competency must have the appropriate
Competency? education and experience to evaluate the complexity of testing being assessed.

▪ Waived testing – qualifications of assessors may be determined by the

laboratory director.
▪ Moderate complexity testing – must meet technical consultant
qualifications.
▪ High complexity testing – must meet general supervisor qualifications.

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The laboratory director is responsible for implementing and maintaining an

Who is Responsible?
effective competency assessment program.

Outcome of an The laboratory benefits include:

Effective System
▪ Ensuring employees are performing and recording laboratory tests and
associated functions according to the laboratory procedures.
▪ Identifying problems with personnel performance to limit impact on
patient care.
▪ Having processes to retrain and reassessing personnel when
problems are identified.
▪ Maintaining ongoing compliance with CAP requirements.

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QUALITY MANAGEMENT SYSTEM (QMS)

What is a Quality A QMS is a set of policies, processes, procedures, and resources designed to
Management ensure high quality in an organization’s services. A dynamic QMS enhances all
System?
activities that impact patient care, promoting quality and patient safety through
risk reductions and continuous improvement.

Overview Each laboratory must design and implement a QMS to include components that
accurately reflect the operations of the laboratory. The QMS must cover:

▪ All areas of the laboratory and beneficiaries of service.

▪ All inherent processes, including core and support processes and
procedures, procedures for monitoring processes, and procedures for
improving processes.

Key Components QMS components include:

▪ A document that describes the overall framework of the QMS and the
patient care and client services offered by the laboratory.
▪ A process for identifying and recoding non-conforming events.
▪ A process for investigation of non-conforming events, including root
cause analysis for sentinel events.
▪ A system for monitoring key indicators of quality in the preanalytic,
analytic, and post analytic phases of testing and comparing
performance to laboratory-defined targets.
▪ A process for recording corrective and preventive actions taken for
non-conforming events, quality indicators that do not meet defined
targets, and evaluating the effectiveness of actions taken.
▪ A process for employees and patients to communicate quality and
safety concerns to management.
▪ A process to assess the implementation of the QMS at least annually
for effectiveness.
▪ An infrastructure for the quality management system, including
aspects such as a document control system.

Who is Responsible? The laboratory director is responsible for the implementation of the QMS with
assistance and involvement from the:

▪ Manager
▪ Supervisor
▪ Laboratory staff
▪ Non-laboratory staff (eg, hospital quality assurance coordinator or
safety and regulatory personnel)

Outcome of an The laboratory benefits include:

Effective System
▪ Continually ensuring that practice matches policies and procedures.
▪ Providing opportunities for quality improvement.

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 Guide to CAP Accreditation

▪ Improving patient and/or clinician satisfaction.

▪ Maintaining ongoing compliance with CAP requirements.

© 2022 College of American Pathologists. All rights reserved. PAGE 21

October 2022