How to Avoid the Most Common Lab Deficiencies: Say What You Do, Do What You Say, Write Down What You Did

Spend enough time inspecting and running labs, and you start to see the same pattern show up over and over. A citation gets issued. The lab corrects it. Two years later, a different inspector walks in and cites the same area again. Not because the staff is incompetent. Not because no one tried. Because the fix addressed the symptom and left the underlying process untouched.

Most laboratory deficiencies across CAP, CLIA, Joint Commission, and COLA ultimately trace back to violations of three principles. They're simple enough to fit on a sticky note. Hard enough that the same labs fail them, inspection after inspection.

Say what you do. Do what you say. Write down what you did.

Say What You Do

This means your written procedures reflect what your team is actually doing today. Not what someone intended when they wrote the SOP three instrument generations ago. Not the process you're planning to formalize after the next inspection. What's happening right now, on every bench, and on every shift.

Labs evolve constantly, and documentation rarely keeps pace. A new tube type gets validated. An analyzer gets replaced. A workaround becomes standard practice.  The process changes incrementally, and the procedure no longer fully reflects reality.

Then an inspector asks a tech to walk through a process while following along with the written procedure and finds they don't match. That deviation is a citation. More importantly,  it shows that informal knowledge has outpaced formal documentation.

Do What You Say

This is its own failure mode, separate from the first. You can have accurate, current procedures that staff don't follow because no one communicated the change, because the described process is impractical at 2 am with a skeleton crew, or because there's no accountability mechanism that would surface the gap.

If you update a procedure and don't retrain staff, you haven't really updated it. You've just created a new version of the same problem.

Write Down What You Did

This is where the most avoidable deficiencies live. Documentation needs to be complete, timely, and meaningful. Not batched. Not backdated.

Backdating deserves its own moment because it's more common than anyone admits and more serious than most people treat it. When a lab reviews June QC data in November and enters the review date as June, that's fraud. It's not a paperwork technicality. The entire point of timely review is to catch problems while there's still something to do about them. A June QC issue reviewed in November either resolved itself or could have been quietly affecting patients for five months. The date isn't a formality, it's evidence that the review actually meant something.

Beyond backdating, there's a subtle version of this failure that's just as common: documentation that exists but doesn't demonstrate any real thought. A signature on a QC chart with no trending notes, no flagged concerns, and no follow-up on a reagent lot change that caused an obvious shift. An inspector sees that and knows immediately that the review is a checkbox, not a process.

Why the Same Labs Keep Getting Cited

The reason these three principles keep generating citations isn't that lab professionals don't understand them. It's that the systems meant to support them are often absent or fragile.

Temperature logs go incomplete not because a tech forgot once, but because there's no backup process when that person is out sick. Competency assessments pile up because they're all scheduled in the same six-week window with no centralized tracking and no escalation when someone falls behind. QC review happens without interpretation because no one ever defined what a meaningful review actually looks like.

What’s missing in each scenario is structured accountability- who owns it, how it’s tracked, and what happens when it doesn’t occur.

The citations are symptoms. The three principles are where real diagnostic work starts.

Beyond the Quick Fix

Labs don’t get cited because they don’t care. They get cited because their systems don’t enforce alignment between policy, practice, and proof.

When documents drift, when events aren’t tracked, when competency isn’t visible, and when accountability is informal, the three principles break down.

Our Lab QMS platform connects document control, inspections, events, competency, training, and operational oversight into one structured environment- so “say what you do, do what you say, write down what you did” becomes standard practice, not aspiration.

If you’re ready for a more resilient quality program, we’re ready to show you how.

→ Explore the MediaLab by Vastian Lab QMS Platform

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