Virtual Accreditation Inspections – A New Normal
Ms. Mashhooda Rasool Hashmi,
Manager Quality Assurance
It was the start of year 2020 and quality assurance group was waiting for the re-accreditation inspection date for our four outreach labs by College of American Pathologist (CAP). I was emphasizing my group members to ensure preparedness as the dates can arrive anytime. COVID-19 infection was spreading in the world except few countries like Pakistan and uncertainty was everywhere. Suddenly an email came from CAP sharing their limitations to travel and extending the re-accreditation for further six months.
Having your laboratory inspected by a group of external inspectors is a basic requirement to get the accreditation or re-accreditation certification. Clinical Laboratories of Aga Khan University Hospital (AKUH) participates on the Laboratory Accreditation Program offered by College of American Pathologist (CAP) – the gold standard. This includes the on-campus lab in Karachi as well as eight outreach labs. As COVID -19 strikes in the year 2020 in Pakistan, four of our outreach labs and one on-campus lab were due for re-accreditation inspection while four of the outreach labs will have to go through the initial inspection to get certified by CAP. Because of the rise in positivity rates all over the world, rise in death toll and travel restrictions led to the delay of about two years for the inspections to happen. AKUH being a JCIA certified hospital and having experience of going through the virtual inspection by the JCIA auditors, it was proposed to CAP by the Clinical Laboratory leadership to arrange the virtual inspections. At that point in time, CAP was not comfortable with the virtual inspections, but the list of overdue inspections was increasing day by day.
Finally, in the last quarter of the year 2021, CAP contacted our CAP director for finalizing the dates and modes of inspections. Our on-campus lab in Karachi got inspected in March 2022 by the set of nine inspectors through an in-person inspection. However, it was mutually decided between CAP and AKUH Clinical Lab that the inspections of outreach labs will be done virtually. Four outreach labs due for re-accreditation were inspected in May 2022 while four labs due for initial inspection were inspected in August/ September 2022. IT department was taken onboard for ensuring the seamless network connectivity. All resources like required for conducting the virtual audit were arranged for each lab. Quality Assurance Group of labs played a vital role in efficiently leading the virtual inspections. The experience was confusing, exciting, and very unique in nature. It led to the inception of a new inspection process; virtual accreditation inspections – a new normal.
