Collaborate with the laboratory at a public hospital in one of America’s largest cities to ready the organization for a College of American Pathologists (CAP) survey. The CAP accreditation includes 1,000 requirements in 21 focus areas and has a reputation of being one of the hardest to attain.
QHR Health Solutions
Darlene Hines, BSHS, MHA, Senior Consultant, QHR Health Clinical Solutions, led the engagement to ready the lab for inspection. She brought her three decades of experience in operational implementation and administrative and strategic planning to the three-month sprint to CAP inspection. Beginning with the CAP checklist, Darlene prioritized the areas in need of most improvement, created and documented processes, developed systems, trained lab staff and marshalled the necessary resources and support.
The CAP inspection found only three very small findings, leading to CAP accreditation of the lab.
“Our lab was due to be inspected within three months of my being hired as the new Administrative Lab Director. QHR Health was able to kick start the inspection readiness process before I came onboard and continued to provide assistance all the way through the day of inspection. It helps to have an independent set of eyes to thoroughly look at everything because there are so many things you can easily overlook in your own surroundings. QHR Health also brings deep knowledge of hospital regulatory requirements and laboratory standards.
There were also a number of equipment needs that we had, and QHR Health was able to help us escalate the issues to senior leaders to ensure our needs were met. Everything came together and we had a successful inspection! We are grateful to Darlene Hines and the rest of the QHR Health team that helped us along the way!”
Administrative Lab Director
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