The Accreditation Committee of the College of American Pathologists (CAP) has awarded accreditation to Brigham and Women’s Faulkner Hospital’s Main Laboratory based on results of a recent on-site inspection as part of the CAP’s Laboratory Accreditation Program.
The CAP uses a peer-based inspection model. On the day of BWFH’s survey, a team of practicing professionals from South Shore Hospital who are qualified through CAP training used CAP accreditation checklists to survey the laboratory for compliance with program requirements. The goal of the survey is to ensure compliance with the most comprehensive scientifically endorsed laboratory standards in order to maintain accuracy of test results and ensure accurate patient diagnoses.
BWFH had a 90-day window in which to expect an unannounced visit from the CAP inspectors. On the day of their arrival, BWFH’s laboratory was subjected to intense scrutiny. “They went through every single question,” says Laboratory Director Rachel Ambacher. “We felt like we were really inspected. You feel good at the end of the day when they don’t have too many findings upon such an intense inspection.”
Ambacher credits her staff for the role they played in the process. “The staff did very well. They were very engaged,” she says. “The inspectors spent a lot of time in the lab talking to staff and asking questions. Everyone was well educated and trained with what they needed to know.”
Like any survey, some minor findings were expected. But the overall feedback was very positive. “The CAP inspector who headed the team was very pleased. He said it was a very well run lab and he would not hesitate to recommend this laboratory,” explains Ambacher.
BWFH is now accredited by the CAP for the next two years. In the interim year, the laboratory is expected to complete a self-assessment which the surveyors will review when they visit again in 2019.
