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Team Memo

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Cover Memo for Team Member Packet (Template)

DATE:

TO: Inspectors

FROM: (Team leader)

SUBJECT: Lab inspection at (name of laboratory)

Enclosed please find your packet for the inspection at the above-referenced laboratory on (date).

Before the inspection, we’ll have a meeting of the team to go over logistics and answer any questions you may have. (Enter Date, time, and location of pre-inspection meeting)

Travel arrangements are as follows: (Enter Travel and hotel arrangement, etc.)

The inspection will begin at (Enter Time inspection will begin, etc.)

In preparing for the inspection, I recommend that you review sections pertinent to your area(s) in the CAP’s Laboratory Accreditation Manual at www.cap.org; from the home page, select Laboratory Accreditation; select Information for Inspectors; select Laboratory Accreditation Program Manual. Print out the appropriate pages.

Before the inspection, please also review:

1. The test list and the performance of the laboratory on proficiency testing. The printout entitled Variant PT Performance by Laboratory lists PT scores of less than 100% for the last two years. I recommend that you focus on these during the inspection to determine if appropriate corrective action has been taken. The laboratory should have copies of PT exception reports completed by the laboratory and approved by the CAP for items with an asterisk. During the inspection, verify that the laboratory is either participating in a PT program or using another system to verify accuracy - the test list indicates which is appropriate for each test.

2. Extent and type of deficiencies noted at the last inspection. During the inspection you should determine whether or not these deficiencies have been corrected.

3. Number of FTE’s in your area in relation to the workload (i.e. volume and variety of tests).

As part of the inspection of your area(s), please observe lab personnel during their work and note whether they use appropriate safety precautions. In addition, please note whether the following items meet safety standards, and report these to the team leader during our pre-summation session:

1. Fire extinguishers and eyewashes are appropriate for your area and located where needed.

2. Appropriate use of protective clothing and universal precautions by all personnel.

3. Evidence of electrical checks (look for tags on equipment) on all electrical equipment, including computer equipment, terminals, printers, etc.

4. Security of compressed gas cylinders.

5. Use of safety cans for hazardous chemicals >1 quart.

6. Flammables: On open shelves, no more than one gallon per 100 square foot of lab space: 2 gals /100 square foot in safety cabinets.

7. Infectious waste in biohazard and/or sharps containers, appropriate.

The Deficiency and Recommendations forms, (pink and yellow forms, respectively), are attached to their respective checklist(s). Please be specific in your comments. The forms should be completed and signed by you before Summation Conference; a copy will be left with the laboratory.

A reimbursement form is also enclosed. It is essential that you submit receipts for all of your expenses. Please return the completed form and receipts to me no later than the day after the inspection.

Please plan to return all of the contents of this packet (except for the checklists) to me at the conclusion of the inspection.

Many thanks for your help. I look forward to working with you.

Insert your name and signature (Team Leader)

-----------------------

Instructions to the Team Leader –How to Use this Template

The cover memo template (below) should be personalized by the Team Leader and attached to the Team Member Packet. A packet unique to each team member, based on the areas each will inspect and the checklists each will use, should be created and distributed to each team member several weeks before the inspection date, and include: • Laboratory demographics page • Inspection Summation Report (ISR) pages and previous ISR pages • AU activity menu pages and instrument list(s) • Variant PT Performance by Lab report • Customized checklists •…...

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