Recipe for a Successful Inspection

By Ginger A Baker, MS, MT(AAB)

Objectives

1. The key to success is education

2. Preparing documentation for inspections

3. How and why to remain calm

4. How being a charming and helpful host can improve your outcome

Recipe for a Successful Inspection

1 part education

1 part organized documentation

1 part calm

Dash of 1950s hostess

EducationEducate yourself.

• Know what your end users really do – not just what policy indicates they SHOULD be doing.

Talk to your peers.

• What did their inspectors focus on?

• What were they cited for?

• Get on update mailing lists, listservs and e-boards

EducationKnow your regulatory requirements.

• Plan time twice a year to review revisions and new regulations

• Look beyond the Laboratory

• Read the notes on the regulation interpretation

POC.03800 Phase II N/A YES NO (Fall 2009 CAP POC Checklist)

 

Is there an appropriate person available on all shifts to assist with troubleshooting or other unusual situations?

 

NOTE: This individual may be from the nursing service, laboratory, or medical staff. The intent is to

ensure that resources are available to quickly assist with unusual problems to minimize any

adverse impact on patient care.

EducationPrepare a list of questions an inspector is likely to ask

staff performing POCT.

• What would you do if you thought the glucometer was not functioning properly?

• Where would you go to see medications that could cause inaccurate glucometer results?

• Who performs QC?

• Who performs patient testing? Knowing how they will answer these questions can protect you.

EducationShare these details with POCT operators.

• Educate POC operators on:

•Who will come

• How they will arrive

• How they are likely to inspect POC

•What is and is not acceptable behavior with an inspector

EducationPerform regular spot inspections all year long.

• Be the inspector

• Provide feedback to staff and managers in areas using POCT

• Practice makes perfect

Recipe for a Successful Inspection

1 part education

1 part organized documentation

1 part calm

Dash of 1950s hostess

Organized DocumentationHaving a well-organized system for maintaining documentation will impress upon your inspector that you are on top of your game.

Bad Good

Organized DocumentationSubfolders or tabs for quick location of required

materials help the inspector perform the inspection and help you ensure you have met your requirements.

• Methodology information

• Validation

• AMR validation

• Semi-annual correlation

• Issues

Organized DocumentationKeep your proficiency testing results together by year

with subfolders by test and include a system for flagging failures.

Keep proficiency testing materials grouped by site number.

Know exactly where to obtain operator credentials and from whom.

Have an example on hand with instructions and information on it.

Organized Documentation

Have a checklist available for operators.

It is amazingly powerful to give them the tools to see what you have to deal with and why your program is structured the way it is and how it empowers them to get the answer for the inspector.

Organized Documentation

Create a flow chart for each POC test – patient care, electronic information and supply chains.

Organized Documentation

Keep everything current.

• Link certification reviews with annual SOP reviews

• Plan and perform each task in your day as if you are preparing for the inspection – because you are

• Never put off dealing with an issue of documentation

• Put documents into your filing system immediately

Recipe for a Successful Inspection

1 part education

1 part organized documentation

1 part calm

Dash of 1950s hostess

Calm

It goes without saying that if you look guilty, you are guilty.

Your inspector is someone just like you. They are there to perform an important job. They want it to be as quick and painless as you do. And they want to learn from you.

Treat this as an opportunity to show off your hard work and the great job your operators are doing.

Calm

Some inspectors feel their job is to always find fault.

If you have something that is a struggle for you, throw them a bone. They’ll spend most of their time documenting what you already know and making your case for you.

Calm

Inspections are a learning exercise. Like exams in school, they can be nerve wrecking.

Just smile, breath and remain calm.

This is your chance to see the great work you do though another’s eyes.

Recipe for a Successful Inspection

1 part education

1 part organized documentation

1 part calm

Dash of 1950s hostess

1950s Hostess

In the 1950s, visiting someone’s home was a very formal affair. The hostess’s job was to have a nice assortment of snacks and beverages, ensure the guest was comfortable and keep the pace moving without seeming pushy.

Miss Manners would say,

“The care and feeding of your inspector

should be addressed with the same level of

detail as your documentation.”

1950s Hostess

As soon as the general tour and introductions are complete, you are ready to pair off and take the time to provide your inspector with your own tour.

Take the opportunity to get to know your inspector.

• Ask about their “normal” job, families and – most importantly – how did their last inspection go?

• What did they get cited on or surprised by?

This is your clue to things they will make a beeline for.

1950s Hostess

• Show them their work space and ask if it will be acceptable.

• Have a fresh note pad, pen and pencil at their work space.

• Have bottled water and a couple snack options available. I always kept power bars, nuts, granola and chocolate in a “survival” kit. A small dollar store basket of comforts goes a long way.

1950s Hostess

• If you must continue to see to your duties, make a phone available to your inspector with a list of your immediate pager or cell phone numbers.

• Ask how they would like to proceed.

Some inspectors want to go out and see what operators are doing and then trace backwards through QC, certifications, supply handling and testing documentation. Others want to see the documents first to know what policy states they should be doing. Some want you within eyesight. Others would prefer you find other things to do and just check back every so often.

1950s Hostess

• Remember, make them welcome in your “home” with every convenience and opportunity at their fingertips.

• Don’t argue. If you’ve debated an interpretation of a regulation without reaching a compromise, take the citation and make your case with the accrediting body. Arguing will only create hostility and break down communication through other processes.

Recipe for a Successful Inspection

1 part education

1 part organized documentation

1 part calm

Dash of 1950s hostess

A Tale of Two InspectionsWhich site would you like to inspect?

The site gave us a facility tour while space and refreshments were arranged.

Everyone was introduced and business cards exchanged.

We were shown to a large room with many tables, labeled with each section and ALL the documentation possible was on library carts and tables next to the labeled area.

The organization chart was posted with their phone numbers and three phones were in the room for our use.

A buffet of refreshments was laid out – water, coffee, tea, sodas, fruit, healthy cookies, chocolate.

Someone checked on the room every 30 minutes.

Lunch was a family buffet style affair where everyone directly involved dined together and conversed.

Patient care area visits were guided and the staff was very friendly, open and knowledgeable.

There were a couple citations, but very few.

A Tale of Two InspectionsWhich site would you like to inspect?

One inspection I went to required a four hour drive from the nearest airport through narrow, winding, mountain roads. There was one motel and eatery in town, and neither were very nice.

Our site left our group waiting in the lobby for more than two hours without explanation, apology or social graces.

They provided a room that only accommodated three people, while our group contained six people.

The Lab Director pointed to the documentation and told us that if it was important that we look at it, we could get it ourselves.

No refreshments were provided - not even directions to refreshments.

No one accompanied me to the patient care areas to see operations.

Staff were openly hostile and uncooperative in answering questions, including the Lab Manager and Medical Director.

They were angry that they received many citations due to our inability to validate performance due to their lack of participation.

Recipe for a Successful Inspection

This is an opportunity to . . .

Make new friends and peer resources

Learn what others are doing

Improve your Point of Care Program

Share the great and important job you do

Recipe for a Successful Inspection

Q & A

Thank you!