Survey / Inspection / Assessment preparation

[Cliff]

How do you prepare your facility, especially the staff for any pending assessment you may have? I fully support that facilities should always be prepared; however, that is not always the case.

With you response, please tell us what type of a facility you are and how many FTE's you have.

We have aaBB and JCAHO lab in Jan - March 05, and our State DPH in December / January.

[Elaine Viggiano]

The most obvious tool to use is the Self Assessment lists that should be provided by the Accreditation agencies. If they are taken seriously, and each question is truly examined, this should be adequate to prevent "show stoppers" from happening.

The operational processes should also be evaluated by touching on the Quality Essentials as you review them. For example, if you are looking at your "crossmatch" process, you can pull in Equipment, Audits, Reagents/Suppliers, QC, Facilities, Computers, Records, etc. to be sure they are in compliance.

I am employed in the Quality Assurance Department of a large Blood Center

[John C. Staley]

In addition to all the good things Elaine suggested I will also take the "check list" and note all the applicable SOPs for each question. That way I can get to the references immediately and not fumble around. I've fumbled around and it is not fun. I always hated telling an inspector/assessor; "I know it's here somewhere!!" As far as preparing the staff, I just tell them it is business as usual, answer any questions in a freindly yet short and consise manner and for heavens sake don't do more than just answer the question. If yes or no works use them.

[Gloria]

In addition to all the good things Elaine suggested I will also take the "check list" and note all the applicable SOPs for each question. That way I can get to the references immediately and not fumble around. I've fumbled around and it is not fun. I always hated telling an inspector/assessor; "I know it's here somewhere!!" As far as preparing the staff, I just tell them it is business as usual, answer any questions in a freindly yet short and consise manner and for heavens sake don't do more than just answer the question. If yes or no works use them.

I agree with this suggestion. Last year when were inspected by CAP, I downloaded the CAP checklist and added the applicable SOPs, as a reference, to each question. When the inspector came in, I handed the checklist with the references to him, this way he knew exactly where to go if he had a question. It worked great.

[schorj]

I have been a CAP inspector and AABB assessor for 25 years and I highly recommend having references for SOP's and other documentation with the checklist that you can show the inspector when he/she comes to your facility. First impressions are always important and if I see that the BB supervisor is well prepared for the inspection, I usually find that the inspection goes very well.

In preparation for the inspection, you might ask your chemistry or hematology supervisor to "play" inspector and ask you all the questions on the checklist. Sometimes, they may see something that you don't because you are so familiar with the questions that you might assume something that isn't actually there. Their perspective can be helpful.

[Laura Mc]

All the suggestions submitted are great. Another idea is to take the self assessment tool or the checklist and give each staff member a section. As them to answer the questions or the checklist items including noting the SOP in which it is located. This also provides another set of eyes and gives the staff member an idea of what an inspector may look for. We have done this for many years and are always surprised (pleasantly so) when a staff member points out an item that we could be doing better at.