Join Karl Wappaus, BlueStone Services’ Client Relationship Manager and Medical Business Advisor Michele Hayward, MHA, MS, CG(ASCP)CM for a short Q&A about CAP laboratory inspections and the importance of CAP accreditation.

In this brief video, you will learn about:

• Common challenges
• Tips to prepare for an inspection
• What BlueStone Services can do to help you pass
• And More!

How BlueStone Services Can Help

Imagine a stress-free lab inspection. Get your lab started off on the right foot—BlueStone Services can identify areas where your laboratory’s performance meets standards and where improvement may be necessary from document management to coats and gloves. We can accurately compile the data needed for inspection for you, so your laboratory personnel can focus on what they do best.

Next Steps

• Learn more about our CAP Inspection Services
• Contact us today to get started with your laboratory set up and accreditation

CAP Lab Q&A Video Transcription

Hi, my name is Karl Wappaus, and I am the Client Relations Director at Bluestone Services. Thank you for joining me today. In this interview, we will delve into the importance of CAP accreditation and how healthcare organizations can initiate and or even enhance, uh, their current lab operations. I am pleased to welcome Michele Hayward, a Distinguished Service Healthcare Consultant with Bluestone Services Medical Business Advisors Division.

Michele has an impressive 25-year history having worked with renowned diagnostic and clinical research corporations such as Quest and Covance Laboratories. She has also provided consulting services to startup laboratories, offering specialized support in quality management and regulatory compliance.

Welcome, Michele. Let’s get right in. Uh, why is CAP accreditation, uh, important to a medical laboratory? Well, Karl, as you may know, physicians rely heavily on laboratory testing to make critical decisions on patient care. The CDC estimates that roughly 70 percent of healthcare decisions made by physicians depend on laboratory testing results.

Therefore, a CAP-accreditation laboratory is recognized and trusted by healthcare providers as meeting the highest standards of quality, and in turn, This level of quality ensures that these laboratories usually meet or exceed regulatory standards. In addition, this level of quality reassures clinicians that they are making clinical decisions based on reliable diagnostic results.

Additionally. Being or becoming a CAP-accredited laboratory offers some additional advantages. It can also increase the laboratory’s chance of becoming in-network with certain payers, which could result in gaining access to potentially untapped sources of revenue. Great, thank you. Next question. Can you describe your experience with CAP lab inspections?

in your role in preparing for them? Well, I’ve worked in the medical laboratory space for over 23 years and have been through numerous CAP and self-inspections, as well as being a CAP inspection team member. And over the years, I’ve developed a unique and thorough process for helping laboratories prepare for a CAP inspection.

This process has resulted in numerous inspections where Either there were only a few citations or many times none at all. I find it extremely rewarding to train and share the knowledge I’ve obtained throughout my career with laboratories that are either just starting out or even those that are well-established.

Helping labs achieve their accreditation ensures good laboratory results and ultimately improves patient safety, which ultimately helps reduce healthcare costs. Why is it important to be prepared for inspection? Well, just like studying for an exam preparation is the key to success. And since medical laboratories are 1 of the most heavily regulated industries, being CAP-accredited ready means that you can mitigate any potential compliance issues.

CAP preparedness also ensures that you Follow best practices and constantly refine and update your processes to meet those standards. Standards are always evolving and staying on top of compliance changes is critical to maintaining testing quality and accuracy. So what are some of the common mistakes labs make while preparing for their inspections?

Well, in my experience, 1 of the most common mistakes, I think, and preparing for an inspection is trying to prepare 6 months or less prior to an inspection CAP or any other inspection preparation should be an ongoing process. Underestimating the amount of time needed to prepare will certainly set you up for failure.

I think it’s also important to mention that the staff who will be interacting with the inspection team not only have to manage the day-to-day of running their sections… but, we’ll also need sufficient time to address any regulatory changes. They’ll also need to develop appropriate process revisions, which ultimately need to be reviewed and approved by the laboratory director.

In addition, I think 1 of the biggest pitfalls and inspection preparation is only preparing supervisors or managers to interact. With CAP inspection team members, I’ve, I’ve seen on numerous occasions where CAP inspectors have directly interacted with a technologist or technicians during the inspection.

The preparation should definitely include making staff comfortable and knowledgeable about the laboratory’s policies and procedures involving them in the preparation will help ensure that the staff is confident and comfortable answering any questions. And then specter might have this preparation also reinforces that your staff is adhering to your policies and procedures.

In my opinion, not investing the time and effort at this point could mean unnecessary citations and the need for time-consuming remediation. So, how does your team involve lab staff and compliance? That’s a great question and a really important question. Uh, the supervisory and technical staff need to feel confident and knowledgeable about the laboratory’s policies and procedures.

And one way to do this is by simulating an inspection, or as it’s known a mock inspection. In my experience, this is one of the best techniques for helping ensure your staff is ready for the CAP inspection by empowering staff to feel confident about the inspection process. It ultimately helps make for a seamless inspection process.

Also, when. Policies or procedures need to be modified involving staff and the writing of those changes is a critical component for ensuring adoption and compliance and my experience staff feel they can provide their input during the policy and procedure. Uh, modifications are generally more willing to embrace those changes, which ultimately means preventing staff workarounds, which could result in sighted deviations during an inspection.

Again, getting staffed early on is a critical component in the quality improvement process. So how does your team handle discrepancies found during inspections? Our preference, and we consider best practices, is to help our clients to identify and address any deficiencies prior to an on-site inspection.

And for those laboratories looking to become accredited, we highly recommend reaching out to us even prior to submitting the CAP accreditation application. As you may know, quality improvement is always an ongoing process, and we believe we have the unique capability of helping our clients by providing an impartial approach to performing a mock laboratory audit.

During a laboratory audit engagement, we take the time to review laboratory documentation, assess staff qualifications, and evaluate processes and procedures, as well as simulate the CAP inspection process. And my experience, I believe 1 of the biggest pitfalls that labs encounter when performing a self-audit is being too familiar with their policies and procedures.

As an outsider, we can perform an assessment from an entirely different perspective. Using the data found during our audit, our clients have the opportunity to address any deficiencies long before a real inspection occurs. This gives them a significant advantage. What other laboratory services can you, can Bluestone MBA provide?

Well, Karl, our team is able to provide several different types of services to our healthcare clients. We can offer a single service engagement to a completely tailored engagement. It really depends on what our clients’ needs are. Some of the other services we can provide are such things as, uh, a vendor analysis.

Such as for new laboratory equipment, we can also assist with writing or reviewing of laboratory policies and procedures, as well as providing interim management services, such as a laboratory director of operations. While Bluestone is not a billing company, we are also able to offer revenue cycle management services, such as a full RCM analysis as well as performing billing audits.

Additionally, we’re able to assist our clients with negotiating pair contracts, capturing every bit of revenue possible is critical in ensuring the financial success and longevity of the organization. Basically, our goal at Bluestone Medical Business Advisors is to deliver tailored solutions to elevate and augment.

the operational efficiency and financial performance of our healthcare clients. We strive to help healthcare organizations increase revenues, which in turn ensures their continued financial and operational success. Well, Michele, thank you again for joining us, and thank you for the insight that you provided on Bluestone.

Really appreciate your time today and look forward to working with you in the future. Thank you, Karl. It was a pleasure meeting with you today.

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