Inspection dos and don’ts

To endure inspections, do this!

Clinical and operational inspections – for accreditation, certification or for processes – can be stress-inducing but Supply Chain professionals can reduce that stress by focusing on the following tips.

“Tell staff not to be nervous if approached by a surveyor but to act normal and answer all questions truthfully – even if it means they don’t know the answer but that they know where to find the answer.  Have other staff from different hospitals do walk-throughs to provide that outside eye. They notice things that are not obvious to some that are too close to the operation.”

John Gaida, Senior Vice President, Supply Chain, Texas Health Resources, Arlington, TX

“You need to be certain that the policies and processes that you have in place are actually being applied at the staff level. It is sometimes the ‘aha’ moment when you discover a procedure or process isn’t being appropriately applied as expected due to laziness or educational lapse.”

Terry Murphy, System Director, Supply Chain, Lee Health, Fort Myers, FL

“Supply chain departments should be ‘survey ready’ at all times. This sounds simple but is harder to implement. On a regular basis employees should be quizzed on how their role relates to the healthcare facility being able to provide quality patient care and patient safety. There should be quality audits performed on how the Supply Chain department is functioning. Is there information available on line-item fill rates from vendors and to customers? Have all items been identified as to their priority and safety stock needed? Are there procedures for emergency orders, etc.? Audits should be performed and reported on at scheduled staff meetings. Make sure employees know how they and their departments are doing and how this can directly impact patient care.”

Donna Swenson, Chief Quality Officer, Quality Processing Resource Group LLC, Ashburn, VA

“In pharmacy, we find that [The Joint Commission] surveys [are] for compliance to other regulatory changes from FDA, DEA, Department of Health and State Board of Pharmacies. In the past year, we have had significant changes to USP797 for intravenous preparations as well as a newly introduced focus hazardous drugs under USP800. Pharmacy supply chain plays a key role in the interpretation of the new requirements as they apply to hospital and continuum of care operations.”

Mary Beth Lang, ScD, Executive Vice President, Cognitive Analytics Solutions, Pensiamo, and previously Vice President, Healthcare Pharmacy and Supply Chain Management Commercial Services, UPMC , Pittsburgh, PA

“Be aware of industry events that may trigger audit attention within your facility: For example, reports on patients who acquire infections in a hospital due to improperly or inadequately reprocessed [gastrointestinal] scopes, patients who develop infections due to tissue that had compromised sterility. Even if the event happened in a geographically distant area it will be on the auditor’s radar and your facility needs to be prepared with records, documentation, etc.

“Learn from other hospitals within your system. If an auditor fixates on an area within one hospital it is very likely that the same questions will be raised in yours.

“Have an established communication chain to Sourcing for quick access to contracts and documentation. Make sure your Sourcing contacts know you have an audit scheduled or believe one may be coming so that Sourcing is on the alert for requests.”

Nora Frank, UPMC Senior Client Delivery Partner, Pensiamo, Pittsburgh

“Don’t look for possible infractions, look at everything.”

Les Coffman, Senior Manager, Materials Management, Hospital Operations, UPMC

“I fully agree with all points made with regards to readiness at all times. It completely removes the stressors associated with a [Department of Health] or [The Joint Commission] audit – regardless of whether it’s scheduled or not. It all comes back to training the teams and frequent rounding.”

Gary Sargent, Senior Manager, Materials Management, Hospital Operations, UPMC

“If you aren’t already rounding on your end users, do it. Talk to them, get them involved and make them aware of what the impact of a negative survey may mean to them or the organization.

“Prepare your staff. Managers and Supervisors should not the only participants during a survey.

“Ask to be part of your mock surveys. Accept criticism when necessary and learn from it. It will ultimately make you a bigger part of the team and overall better team because of it.”

Joe Goyne, Senior Director, Logistics, Geisinger Health System, Danville, PA

“Documentation is the key to success for all Joint Commission inspections. During an inspection, Joint Commission personnel are looking for proof of adherence to the policies and procedures that a hospital has defined for its operations. Documentation is that proof. Too often, the necessary data resides in different systems, spreadsheets or is known solely by an on-site expert. Maintaining ongoing, well-organized documentation can help ensure that accurate reporting is possible at inspection time. Centralizing that documentation by type makes it even easier.”

Jackie McGuinn, Senior Strategic Marketing Manager, GHX, Louisville, CO

“There is one common, well-known requirement: No product or obstruction shall be less than 18 inches from any and all sprinkler heads. The 18-inch requirement – measured a full 180 degrees below the head – allows for a sprinkler head to fully function properly for the intended spray of water, and also for safety, damage prevention, etc. Consequently, it is important that the 18 inches is precisely measured from the actual sprinkler head where the water comes out to any product or obstruction.

“During an inspection, the storeroom manager at one of our smaller hospitals proudly pointed out how they placed visible tape on the wall around the perimeter of the store room at 18 inches below the sprinkler system/sprinkler head, thus were able to eyeball how high they could go when placing items on top of the shelving units. Unfortunately, this gave the clerks a false sense of compliance as long as the box did not appear to encroach on the 18-inch limit.

“The inspector, accordingly after being presented the compliance maneuver responded, ‘Okay, let’s see’ and pulled out a tape measure. For the most part, all items were positioned over the 18-inch requirement, except two boxes that happened to be slightly open. While the 16-inch height of the closed case met the measured distance requirement, the partially opened box flap added four inches to the height and caused a non-compliant occurrence. The inspector was not trying to nitpick, but took the time to explain the regulation and point out the deficient situation. The manager made it worse when he commented, ‘We are supposed to store only full cases on top.’ The inspectors reply: ‘Really? Show me your policy or procedure for that,’ which could not be produced.

“While a minor citation was given, the lesson and information proved valuable. Eighteen inches is 18 inches all the time! And procedures, especially safety procedures, need to be in writing!”

Don’t do this!

When faced with any kind of inspection – for accreditation, certification or for operational behavior – Supply Chain professionals offer the following advice on what not to do and how to fix.

“Panic. It does no good.”

John Gaida, Senior Vice President, Supply Chain, Texas Health Resources, Arlington, TX

“We should not work under the belief that these accreditation surveys are annual. Our practices need to be completed at the highest level of attention at all times.”

Terry Murphy, System Director, Supply Chain, Lee Health, Fort Myers, FL

“The big thing to avoid in any inspection is to have an employee tell a surveyor that they ‘don’t know.’ It is okay not to know, but the employee should know how to get the information. The response should be ‘I don’t know, but I can find that information for you by . . .’ and then proceed to show how she or he finds the information requested. To get this response from employees it is necessary to work with them and review what appropriate responses to a surveyor would be. This can be done by training, which includes role playing.”

Donna Swenson, Chief Quality Officer, Quality Processing Resource Group LLC, Ashburn, VA

“Failing to learn from past mistakes. If it was an issue during the last audit it will come up again.”

Nora Frank, UPMC Senior Client Delivery Partner, Pensiamo, Pittsburgh, PA

“Waiting until the last moment to prepare the team.”

Les Coffman, Senior Manager, Materials Management, Hospital Operations, UPMC

“Readiness and compliance to [The] Joint Commission requires ongoing surveillance for readiness. Relying on just one form of education for staff readiness is not enough. We have found that we need to include training in new hire orientation for the organization and the department. All staff take yearly competency training sessions on all underlying patient and employee safety aspects that are tied to The Joint Commission readiness. We also train staff on the UPMC culture of excellence to focus on key dimensions that support providing patient-centered high quality of care.”

Mary Beth Lang, ScD, Executive Vice President, Cognitive Analytics Solutions, Pensiamo, and previously Vice President, Healthcare Pharmacy and Supply Chain Management Commercial Services, UPMC , Pittsburgh, PA

“Never under-prepare. Treat each day like it’s a survey day. Own the Supply Chain. We all know things happen, things get missed and last-minute scurrying by end users often times affects your preparation. Own the issues and work with end users to build processes that everyone could trust.”

Joe Goyne, Senior Director, Logistics, Geisinger Health System, Danville, PA

“Don’t appear unprepared. If an organization’s policies and adherence to them is well documented, the inspectors will find little reason to keep digging below the surface and potentially find problems. Raise red flags through poor documentation and you invite a grueling, in-depth inspection.

After any inspection, most organizations breathe a collective sigh of relief. The reality is that the clock has just begun ticking towards the next inspection, even though it won’t take place for another three years. So, don’t wait.

“Don’t wait to improve your vendor management processes. Find a vendor solution or enlist the help of a third party. Credentialing systems, though not perfect, help establish well-defined processes and make it easy to provide the appropriate documentation. The more control a hospital has over its data, the easier inspections will be.”

Jackie McGuinn, Senior Strategic Marketing Manager, GHX, Louisville, CO