CAP Requirements

GEN 20262

• The Quality Management Program should include the review of errors, complaints and incidents at defined intervals to identify trends and initiate corrective/ preventative actions as appropriate.

GEN 20366

• The laboratory must have a procedure that encourages employees to communicate any concerns or complaints with respect to the quality of patient testing and safety.

• The investigation and analysis of employee complaints and suggestions, with corrective and/or preventive action as appropriate, should be a part of the laboratory quality management plan and specifically addressed in laboratory quality management records.

GEN 20367

• While personnel should report concerns to laboratory management, the laboratory must ensure that all personnel know that they may communicate with CAP directly if they have a concern not addressed by laboratory management, and that CAP holds such communications in strict confidence.

• The laboratory must have a policy prohibiting harassment or punitive action against an employee in response to a complaint or concern made to CAP or other regulatory organization regarding laboratory quality or safety.