WRNMMC, Bethesda, Md.   –   The College of American Pathologists (CAP) recently reaccredited the Department of Pathology and Laboratory Services at the Walter Reed National Military Medical Center (WRNMMC) after an extensive document review and an on-site visit by some of the country's best pathologists. It's all part of a process every two years to ensure that CAP-certified labs meet strenuous public safety and medical excellence standards.

Pathology: An Up-Close View

Military pathologists conduct tests on tissue, cells, and bodily fluids to diagnose disease and collaborate with other medical officers and technicians in performing anatomical and pathological examinations involving tissue preparation for microscopic analysis, such as biopsies and necropsies. They conduct laboratory tests and examinations of blood, organs, and body tissues to determine the etiology, nature, and development of diseases and disease processes.

Victory Loves Preparation

"The preparation for a CAP inspection is a meticulous and comprehensive process," shared U.S. Army Col. (Dr.) Jason DeBoer, who is the deputy department chief of pathology and laboratory manager at Walter Reed. "Our approach is twofold: ongoing quality assurance (QA) and focused preparation for the inspection."

Quality Assurance

According to DeBoer, throughout the year, the pathology department maintained a robust quality management system aligning with CAP standards. The pathology department's preparation included regular internal audits, proficiency testing, staff training, and process improvement initiatives. That continual vigilance ensured we consistently adhere to the highest standards of laboratory practices, said DeBoer.

Focused Inspection Preparation

"Staff engagement is key; we hold departmental meetings and training sessions to ensure all personnel are well-versed in CAP requirements and ready for the inspection process," shared DeBoer – who is a medical laboratory scientist (MLS) certified by the American Society for Clinical Pathologists (ASCP), the gold standard in global credentialing for medical laboratory professionals, which has credentialed more than 610,000 individuals.

DeBoer praised U.S. Army Lt. Col. Carlos Barrea, the department's quality assurance manager, for championing Walter Reed's preparation process and ensuring that the team addressed all aspects of the inspection process.

Document Submission: Extensive Undertaking Requiring Attention to Detail

"The document submission is not a standalone task, but a culmination of continuous record-keeping and quality monitoring," shared DeBoer. "Although document preparation intensifies in the few months leading up to the inspection, it is, in essence a dynamic and ongoing process integral to our daily operations," emphasized DeBoer.

Barrea excelled in overseeing the extensive undertaking – collating and reviewing thousands of pages of quality control records, proficiency testing results, equipment calibration logs, staff competency assessments, and standard operating procedures.

On-Site Inspection: Presentation Matters

After months of preparation, the CAP inspection team arrived on October 26 ready to conduct extensive facilities checks of Walter Reed's pathology department. DeBoer, Barrea, and U.S. Army Maj. (Dr.) Elaine S. Keung, the pathology department director, accompanied the CAP team throughout its inspection.

"The inspection is comprehensive – it's not just about ticking boxes but making sure we're doing our best work and maintaining our commitment to excellence in laboratory medicine," said DeBoer.

Mission Success: Drilling Down on Integral Inspection Elements

Room-to-Room Compliance Checks: CAP inspectors evaluated sample storage methods, test processing protocols, and overall lab operational procedures.

Securing Data: CAP inspectors ensured that information was secure, confidential, and managed properly.

Equipment Checks: CAP inspectors evaluated equipment for proper calibration, maintenance, and operational accuracy, ensuring the reliability of test results and the safety of our laboratory practices.

Team Accreditation Verification: CAP inspectors reviewed the qualifications and accreditations of our laboratory personnel to confirm that each team member is appropriately certified and trained to perform their designated tasks.

Administrative Review: CAP inspectors ensured that emergency procedures, record-keeping, and quality improvement measures complied with the latest standards.

According to DeBoer, our team met the vast majority of the standards set by CAP, with only one deficiency identified out of 1655 standards evaluated (99.99%). The pathology team's success is a testament to the stringent quality controls and high standards we uphold in our laboratory practices.

"We view the CAP inspection process as an invaluable opportunity for continuous improvement," shared DeBoer. "The fact that no further recommendations were provided by CAP is a significant acknowledgment of the robust processes and high-quality standards we have established at Walter Reed's Pathology Lab."

DeBoer and Department of Health Agency stakeholders agree that the cornerstone of Walter Reed's success is the team: dedicated professionals deeply committed to advancing patient care through collaboration, cooperation, and continued resilience.