Recipe for a Successful Inspection examines the proven recipe for a successful inspection. This recipe has been proven successful over time through many inspections by most credentialing agency. Four simple ingredients can prepare any person in any location to meet the challenges of an inspection.

1. Recipe for a Successful Inspection By Ginger A Baker, MS, MT(AAB)

2. Objectives The key to success is education Preparing documentation for inspections How and why to remain calm How being a charming and helpful host can improve your outcome

3. Recipe for a Successful Inspection 1 part education 1 part organized documentation 1 part calm Dash of 1950s hostess

5. What were they cited for?

7. Look beyond the Laboratory

8. 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.

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

11. Who performs QC?

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

14. Who will come

15. How they will arrive

16. How they are likely to inspect POC

18. Provide feedback to staff and managers in areas using POCT

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

22. Validation

23. AMR validation

24. Semi-annual correlation

26. 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.

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

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

30. Never put off dealing with an issue of documentation

32. 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.

33. 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.

34. 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.

35. Recipe for a Successful Inspection 1 part education 1 part organized documentation 1 part calm Dash of 1950s hostess

36. 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.”

38. What did they get cited on or surprised by? This is your clue to things they will make a beeline for.

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

42. 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.

45. A Tale of Two Inspections Which 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.

46. A Tale of Two Inspections Which 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.

47. 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

48. Recipe for a Successful Inspection Q & A Thank you!