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October 26, 2022

Six Keys to Inspection Readiness in Healthcare

If you work in a clinic or hospital, you already know that healthcare inspections are stress-inducing and scary, and the consequences of failing an inspection are numerous. 

That means when any of the federal or state inspectors, or one of the accrediting bodies pops in for an inspection, it’s all hands on deck. With some advance notice, facilities scramble to get records in order and ensure that everything is exactly as it should be.

What does hospital accreditation really mean, and is it a good indicator of high-quality patient care?
  1. What is hospital accreditation and how does it work? 
  2. Is being compliant the same as offering high-quality patient care?
  3. If accreditation and compliance don’t indicate healthcare quality, what does?
  4. Shouldn’t healthcare quality be a given

Types of Healthcare Inspections

Inspections in hospitals and healthcare facilities are conducted regularly by several different organizations. The federal government (CMS) and the state (the Ohio Department of Health, for example) conduct inspections to ensure standards are being met for patient care. Accrediting bodies (such as the American College of Radiology, and the Joint Commission - JCAHO) inspect facilities and procedures every three years to renew accreditation. And there are independent research organizations that also conduct periodic inspections.

Though each organization has specific intentions and might be looking for different things, the main objective is to ensure that facilities providing care for patients are providing care that meets a set of basic standards.

How can healthcare facilities prepare for inspections?

Ideally, preparedness is more of a posture than a procedure. The best way to get ready for an inspection is to be ready, to make readiness a goal at all times. Easier said than done? Maybe. But here are six keys to keeping your healthcare facility ready for inspections.

1) Know the policy

The policy is the reference document that sets forth the requirements for your department or facility. Have it on hand, and make the rest of the steps outlined here track back to the policy. This is your “constitution.”

2) Establish the guidelines

Your guidelines will dictate the actual tests that need to be performed, the schedule on which they’re completed, what you’ll do if tests exceed or fall short of norms, and how to document the test results. Guidelines tell you what to do, what rules to follow, and what actions to take.

3) Make sure procedures are documented and clear

Procedures are step-by-step instructions that offer specific details about exactly how to set up tests. These should make it easy for anyone in the department or facility to understand what needs to be done. They should list the equipment required and dictate exactly how tests should be run and how the results should be documented.

4) Maintain excellent records

Records must be meticulously kept–these let inspectors know how exacting the standards are and how well staff is adhering to daily testing requirements to maintain quality control in various departments. Ideally, records should be electronic, giving inspectors (and staff) a variety of ways to view important information and set to flag any missing or erroneous entries. At a minimum, records (paper or electronic) should include:

  • Who performed the test
  • Results (data if applicable)
  • Pass/fail
  • Comments/followup
  • Who reviewed/sign off

5) Keep staff training up to date

If staff are expected to maintain records, perform tests, and adhere to other preparatory items, it is critical that staff training be a priority. Training can be made up of various types, but should include:

  • Initial training
  • An annual refresher
  • Re-training as needed (new equipment, new procedures, or failure to perform)
  • Pop quizzes

6) Perform routine audits

Regular auditing helps ensure you’re ready when inspections do pop up. There are different kinds of routine audits you can do, but whether these are performed by in-house staff, peers, or outside consultants, they should be handled just as a regular inspection would be.

For departments and hospitals utilizing electronic QA management like ZapIT, the need for routine audits is essentially eliminated, since this tool offers the ability to assess readiness with a glance. Even with a product like ZapIT on board, a routine review of policies, guidelines, and procedures is still a good idea.

Will you be ready for your next healthcare inspection?

The key to inspection readiness for healthcare is not “getting ready.” It is “being ready.” Being ready for an inspection shouldn’t be stressful. And more importantly, it’s not something that should be looked at as a one-time event. You don’t ‘get’ inspection ready. You maintain readiness at all times.

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In the near future, Enzee’s platform will provide the same features from radiology and radiation oncology to the entire hospital equipment QA program and also connect to existing compliance and test tracking apps, providing a holistic picture of a facility’s compliance and quality across personnel and departments.