Dont Panic It Is Just an Inspection

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Dont Panic It Is Just an Inspection

• Holly Rapp, Director
• Accreditation and Quality
• AABB

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Purpose of an Inspection/Assessment

• To determine compliance with established
  requirements or Standards
• Peer review
• Education

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The Expectation

• You are always prepared for an inspection/assessme
  nt

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• How Do I Get Ready?

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Getting Ready Helpful Hints

• Have a plan!
• Define activities
• Define timeline
• Involve your staff
• To develop policies, processes, and procedures
• To find areas of nonconformance

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Getting Ready Helpful Hints

• Involve executive management
• Practice with staff
• Use outside sources
• Other professionals
• Other hospitals

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Inspection Team Policy

• To facilitate all inspections
• Conduct follow-up meetings
• Ensure completion of corrective actions
• Respond to inspecting agency

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Inspection Policy

• Outlines actions to be taken upon arrival of an
  external investigator or inspector
• Defines the primary facility contact
• Defines whom to notify
• Defines actions and conduct during an inspection
• Defines follow-up activities

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Inspection Policy - continued

• Designated area for the inspector/assessor
• Agenda/timetable
• Assign an escort
• Notes
• Access to records, copying, photographs
• Inspection Team Meetings

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Inspection Policy - continued

• Planned corrective actions
• Implemented corrective actions
• Exit conference
• Summary notes
• Response to deficiencies
• Follow-up for corrective actions

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Be Prepared Things to Make Their (and Your) Job
Easier!

• Master of SOP Index
• Org chart
• List of facility locations, hours

• Training records
• Error summaries
• Quality reports
• Audit Schedules

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During the Inspection Things To Do

• Be factual
• Be honest
• Be helpful
• Be professional
• Ask for clarification
• Think before answering

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During the Inspection Things To Do

• Provide reasonable access
• Minimize conversation
• Understand the question
• Keep answers brief, Yes, No
• Take detailed notes

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During the Inspection Things To NOT Do

• Stretch the truth
• Hide
• Be uncooperative
• Say never or thats impossible
• Add unsolicited information

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During the Inspection Things To NOT Do

• Offer bribes
• Let the inspector/assessor wander
• Make up an answer
• Sign anything or agree to anything
• Break confidentiality

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Other Ways To Be Prepared

• Anticipate commonly asked questions
• Be prepared by
• Knowing the answer
• Knowing where to find the answer
• Knowing your SOPs
• Knowing who in the facility might know the answer

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Other Tips

• Keep answers brief and to the point
• Always refer to a SOP
• Dont offer too much or lead the
  inspector/assessor
• Dont gossip or complain

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Other Tips

• Use good listening skills
• Use good observation skills
• Dont offer suggestions for the inspection
• Dont be misled or mislead
• Treat them as your customer

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Other Tips

• Keep your facilities clean and organized
• Ensure that your SOP manuals are current and
  match practice
• Ensure records are clear, complete with
  concurrent documentation, neat and legible
• Ensure records are regularly reviewed
• Follow-up on problems

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Assessment/Inspection Overview

• Opening meeting
• Tour
• Review of SOPs and records
• Observation of procedures
• Staff interviews
• Summary session

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What Are Assessors Looking For?

• A process to review new standards and
  requirements
• A process to compare new requirements to current
  SOPs
• A process to update SOPs
• A process to approve SOPs
• A process to validate SOPs
• A process to train staff

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Then

• Implementation of processes
• Evidence of review
• Evidence of change control
• Evidence of approval and validation of SOPs
• Evidence of training and competence records

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Anything Else?

• Were nonconformances identified during the
  previous assessment?
• Has the facility followed through on the
  corrective action plan that was submitted?

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Summary or Closing Session

• No surprises!
• What standards/requirements were not met?
• Objective evidence
• Opportunity to ask questions, discuss findings,
  ask for clarification
• Listen closely
• Take notes

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Failure to Meet Requirements

• Nonconformance/deficiency
• A policy/process/procedure not defined or
  documented
• Multiple implementation failures
• Requires the facility to submit a written plan of
  corrective action within 30 days of the assessment

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Corrective Action Plan

• Remedial (immediate) action
• Root cause analysis
• Corrective (long term) action and
• system improvements
• Process control checks (monitoring for
  effectiveness)

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CA/System Improvements

• Description of the action taken to prevent
  recurrence of same or similar nonconformance
• Timeline for the completion of the action
• Individuals responsible for overseeing the
  completion of the action

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Plan for Monitoring CA

• Monitoring the effectiveness of CA is critical
  for ensuring that the causative factors of the
  incident have been identified and corrected

• Indicator tracking
• Error tracking
• Direct observation
• Paperwork review
• Focused audits
• Combination of these

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Im Done Now, Right?!!
NO!
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Staying Ready for Assessments/Inspections

• Implementation and monitoring of CAPlan
• Introduction of New Standards
• Comment period
• Make your thoughts known!
• 4 month implementation period
• Develop a plan
• Implement
• Internal assessments
• Process improvement

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Questions