Sheikh Khalifa General Hospital Discovers CAP Accreditation is an Educational Journey

The College of American Pathologists (CAP) Laboratory Accreditation Program is about accuracy, safety, quality, reproducibility, and a dozen other things. But at heart, it is about building a healthy culture in the laboratory, one that fosters excellence, collaboration, and continuous quality improvement, which ultimately benefits patients. This is the story of one laboratory’s educational journey, the challenges it presented, and the benefits that accrued. 

From the outset, some laboratory professionals at the 195-bed Sheikh Khalifa General Hospital (SKGH) in Umm Al Quwain, United Arab Emirates, questioned the wisdom of pursuing CAP accreditation. Their hospital was still new; in some ways it was still in launch mode. The laboratory team had its hands full covering medical/ surgical, obstetrics/gynecology, neonatal intensive care, pediatrics, intensive care, and emergency patients along with point-of-care testing across the hospital. It might be too steep a mountain to scale just yet, they said. Taking on so complex an enterprise so soon could be courting disaster (the checklists! the documentation! the procedures!). 

Plus, SKGH would be the first hospital laboratory in the Ministry of Presidential Affairs group to seek CAP accreditation, and it’s always risky to be the first. Not everyone saw the necessity. The hospital was already gold-seal approved by the Joint Commission International (JCI). The laboratory had incorporated the CAP’s proficiency testing (PT) programs for all external quality assurance (EQA) from the beginning. It was pursuing International Organization for Standardization (ISO) certification. Did the laboratory also need to be CAP accredited? Was the pursuit realistic right now, given the workload? Was the investment of time and energy justified? Some thought not. 

But the laboratory department head thought yes. For Mubarak Al Faresi, MD, MBBS, consultant medical microbiologist and head of the Department of Pathology and Laboratory Medicine, CAP accreditation had been a goal from the start. SKGH was a well-appointed hospital already caring for an estimated 150,000 inpatients and outpatients each year. Its laboratory was performing more than a halfmillion tests annually. But it was also a new hospital, not well known in the region. CAP accreditation would establish credibility by demonstrating accuracy, professionalism, and reliability. 

Dr. Mubarak had previously worked in a large CAP-accredited laboratory and knew that it would make the environment more professional, give his staff greater confidence, and enable his clinicians to trust laboratory findings when making treatment decisions. He had seen the multidimensional value that CAP accreditation could create, and he wanted it for the patients, physicians, and laboratory professionals under his wing. 

And as his laboratory took the first steps toward accreditation, exploring the checklist and talking through who-would-do-what-first, Dr. Mubarak says, the challenges made his case. Objections faded as everyone in the laboratory realized how interesting and important their work truly was. 

Their first inspection went well, reinforcing the ambitions seeded by their preparation. Everyone on the team had come together naturally around integrating the new knowledge they were taking in with the day-today tasks they continued to perform. The CAP-supplied, customized checklist had been their guide (as it was when they needed to do their interim self-evaluation). Examples in the checklist explained how to show evidence of compliance with the requirements; they were ready, and it had gone well. Once the SKGH laboratory had passed inspection, the laboratory team saw how it felt to be pioneers, qualified to offer confirmatory testing to sister hospital laboratories and mentor those interested in learning more. It was a great feeling.

Among his own clinicians, Dr. Mubarak found that those who had once doubted outlier results were comfortable for the first time. Those who had been inclined to request confirmatory testing at a reference laboratory rarely suggested it. “That changed totally,” Dr. Mubarak says. “Now we tell our physicians, ‘Listen, we are CAP accredited. We can show you our PT performance and our daily quality control.’ And they have confidence in our results.” The laboratory team’s enhanced professionalism, coupled with prominent CAP accreditation signage, had freed his clinicians to focus on patient care instead of questioning the reliability of laboratory test results.

From their first inspection, the SKGH laboratory team had learned that an intrepid undertaking can be a deep dive of the best sort, revealing strengths and encouraging creative thinking about efficiency and safety. Every reason, Dr. Mubarak thought, his team should welcome their first reaccreditation inspection two years later. Yet, as he well knew, no CAP inspection is routine. Reaccreditation is designed to ensure that everyone is adopting current best practices and staying on top of the science as it evolves. With these changes and insights reflected in the annually-updated CAP requirements, every inspection can be as challenging as the first. 

By underscoring the importance of patient care quality and safety measures in the laboratory, accreditation boosts staff competence and confidence while it builds leadership skills. This, in turn, can improve communication and interaction with clinical colleagues. One seasoned inspection team leader who can speak with authority to the ways that CAP accreditation can promote clinical partnerships is Aaron Han, MD, PhD, FCAP, chief of pathology at American Hospital Dubai, which earned its first accreditation nearly two decades ago. 

“When I’m leading a team on an inspection and the hospital CEO and administrator join us for the morning orientation, we stress the practical value of CAP accreditation,” Dr. Han says. “Lab accreditation encourages better compliance with documentation requirements, more uniformity and adoption of best practices, attention to quality control and quality assurance, and less unnecessary repeat testing.” While he is on site, Dr. Han always tries to visit some of those departments that work most closely with the laboratory. “I try to encourage the laboratory teams to see direct interaction with their clinical counterparts as part of good governance. The laboratory drives 70% of clinical decisions and deserves a seat at the table,” he says. 

On November 8, 2018, the second CAP inspection revealed a healthy quality culture securely in place and growing at SKGH. After two years as an accredited laboratory, the laboratory team was proud of its shared competencies; the pre-inspection jitters were still present, but the mood was now upbeat. Staff knew what to expect on the second inspection. They knew that they were prepared, that their inspectors would be well qualified to offer advice, and that they would be comfortable about seeking it.

And two years in, they also knew why accreditation is described as an educational journey. At a CAP inspection, everyone is learning at once. Inspection teams learn new approaches and perspectives from the laboratories they inspect, and the inspected laboratories learn, too.

Peer-to-peer inspection has been the backbone of the CAP accreditation program for more than 50 years because the dynamic is collaborative and challenging. Nobody is about to give anybody the space to fail; at each inspection, accreditation is earned. If performance is suboptimal, you’ll know at the post-inspection meeting that day. CAP inspectors will explain, then and there, what is needed to be eligible for reaccreditation, and the laboratory team will have an opportunity to demonstrate compliance in a reasonable time frame. Lesson learned; move on. At times the deficiencies are corrected on site. Dr. Han was part of one inspection where a second fire exit was lacking, but the director was so motivated that he brought in his facility team, drilling through the cement wall. A new door was put in place within nine hours, well before the summation conference.

The culture of CAP accreditation is premised on mutual respect. Access to new expertise is an intrinsic benefit, with both pathologists and technologists working in CAP-accredited laboratories volunteering as inspectors themselves. This adds immeasurable value to an evidence-based exercise that will continue to build on itself, enabling sometimes-transformational evolution.

“CAP accreditation gave us a clear path,” Dr. Mubarak concluded. “It standardized our procedures in all of our laboratory sections and among our staff, which reduced our turnaround time, lowered our costs, and improved the accuracy of our reports. I am proud to say that our staff is now expert in accreditation and quality laboratory work.”

As he turned to preparations for the MEDLAB meeting, Dr. Mubarak was thinking about one last follow-up task to wrap up his laboratory’s second CAP inspection. He has a small celebration to plan, one that will recognize the hard work, commitment, and stubborn pride of everyone who collaborated to earn CAP laboratory accreditation—and reaccreditation—for the patients and clinicians at SKGH.