The Weed Army Community Hospital at Fort Irwin, Calif., and Yuma Proving Ground, Ariz., laboratories passed College of American Pathologist (CAP) inspections Oct. 8 and Nov. 9, respectively.
First Lt. James Phillips, the chief of pathology for Weed ACH, oversaw the inspection on Fort Irwin.
According to Phillips, the CAP is an accrediting body that regulates every laboratory in the nation and provides a checklist of over 600 requirements that are inspected against the laboratory every two years in person and annually by self-inspection.
“During a CAP inspection, various aspects of the laboratory’s operations and management are evaluated, including procedure manuals, completeness of records, types, and methods of quality control and factors that indicate that the lab is meeting high-quality standards,” the Pascagoula, Miss., native said. “Those involved are the staff of the laboratory, leadership of the laboratory, and an inspection committee selected by CAP.”
Both Weed ACH and Yuma Proving Ground’s labs, which have transitioned under the Defense Health Agency, are required to complete the inspection.
“The laboratory is governed by the Clinical Laboratory Improvement Program (CLIP), which stems from the Center for Clinical Laboratory Medicine (CCLM),” Phillips said. “These programs fall under the newly-developed Defense Health Agency (DHA) for all laboratories.
Pfc. Zachary Jones, a healthcare specialist with Yuma Proving Grounds, participated in the CAP inspection at his clinic.
“To prepare for our inspection, we rechecked all of our [standard operating procedures], datasheets and ensured our documentation was where it needed to be and was up to date,” Jones, a Carbondale, Ill., native, said. “In all, it is a lot of small things.”
Jones and another healthcare specialist run the lab at Yuma Proving Ground in lieu of medical laboratory technicians.
Both Jones and his counterpart have undergone competency assessments for all waived testing that is validated by the officer in charge of point of care testing or the deputy of Weed ACH’s lab before testing can begin, said Phillips.
“They also participate in CAP Proficiency Testing on an annual basis that collaborates with their separately owned CAP accreditation toward in-person inspections,” Phillips said. “Pfc. Jones and Pfc. [Jonathan] Martinez are given sole responsibility of passing inspections, passing proficiency testing, and validations of new personnel with limited oversight from the medical director and Weed ACH leadership.”
As a healthcare specialist, working in the lab can be challenging for Jones, he said.
“At times, working in lab is stressful, but I believe it has helped me in working with circumstances that involve more challenging situations, which I can say Martinez and myself both think have benefited us to become more proficient healthcare workers in the lab,” Jones said.
The proficiency of both labs showed as Weed ACH scored 97 percent and Yuma Proving Grounds clinic scored 99 percent on the inspections.
“The outcome of this inspection is phenomenal,” Phillips said. “It states that the laboratory and command team at the hospital are in support of each other to produce the best and most effective quality of care for our patients.”
Jones said he was “delighted” with the results of the inspection.
“I believe our score on the inspection shows our hard work and thorough effort to maintain our lab to keep it at its highest possible operating standard,” he said.
The facilities have overcome obstacles the past year to achieve their scores.
“As the first community hospital to go live with MHS GENESIS, the military’s new electronic health record system and after establishing the first COVID-19 Mass Testing procedures for the National Training Center, the outcome was outstanding,” Phillips said. “The staff and the leadership in the laboratory are fairly new to running the facility and to have a successful inspection speaks volumes for the future of their careers and the future of effective and efficient patient care for Weed Army Community Hospital department of pathology.”