College of American pathologists (CAP) - compliant policies for the pathology laboratory

Abstract

The pathology department is the key to provide precise diagnosis and efficient patient care, especially in cancer cases. This project started with a comprehensive literature review then recommendations were provided according to the literature findings as well as the suggestion of team. The project last for 4 months. It aimed to carefully examine the general policies and standard operating procedures (SOPs) at Clemenceau Medical Center (CMC) to identify whether they adhered to the standards established by the College of American Pathologists (CAP). The current policies of the hospital were reviewed after the literature review, taking into account the findings of the literature as well as the requirements of international standards. It yielded to the revision of 5 general policies and 70 SOPs ensuring that they are compliant with CAP standards. Furthermore, non-compliant areas were highlighted, and recommendations were given according to the guidelines of the international standards and industries. The policies and procedures had certain flaws and inconsistencies, particularly in documentation, quality control, and safety procedures disciplines; some of which did not follow the CAP standards. Adhering to CAP accreditation requirements plays a vital role in patient safety and maintaining high-quality laboratory services. Obtaining the CAP accreditation promotes an excellent culture in laboratory practice, thus validating and implementing the suggestions provided is of utmost importance.