There are inspector responsibilities once the on-site inspection is complete including:
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Responsibilities
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Performance Evaluation
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Commendable Practices
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Online Resources
After the
On-Site Inspection
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Responsibilities
Once the on-site inspection is over and you return home, the process is not complete. Please remember what you learned is confidential and should not be discussed, even with your colleagues.
Complete your inspection report within three days of the inspection and include:
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The completed Compliance Application.
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The written report, automatically generated by the accreditation portal, includes the applicable standard number and a description of the deficiency. Include a list of missing documents, suggestions for improvement, and any additional comments or recommendations you feel may help the Accreditation Committee evaluate the applicant’s compliance with the Standards. If you are not clear about certain points you made in your notes, you should consult with other members of the inspection team or call the applicant for clarification.
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Additional documentation obtained during the on-site inspection to support your observations (for example, updated forms, RFI responses) should be included as notes to the FACT Accreditation Office.
Within two weeks of the inspection, the team leader reviews the complete inspection report and clarifies any ambiguous deficiencies and missing details. A prompt report is the easiest to prepare, and makes a significant difference to the inspection turnaround time. It allows the FACT Accreditation Coordinator to prepare a summary report for the FACT Accreditation Committee, and for the committee to review this information and make the accreditation decision in a timely manner. Since the Accreditation Committee meets on a monthly basis, a delay in submitting your report could mean the decision will be deferred to a later committee meeting. As an incentive to meeting FACT timelines, your reimbursement will not be processed until your inspection report has been received.
It is very helpful for inspectors to attend the FACT Accreditation Committee meeting during which the organization’s report is being reviewed. The committee relies on inspectors to answer questions concerning the inspected organization. Inspectors receive an invitation from their Accreditation Coordinator to this meeting. After you have been notified the applicant has received FACT accreditation, all materials related to the inspection must be destroyed.
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Performance Evaluation
FACT requests the applicant, the inspectors, and FACT personnel to complete an evaluation of the inspection process after each inspection visit. This helps FACT identify problem areas in the Standards, the inspection process, and inspector conduct. Inspection feedback will be incorporated into future inspector training sessions. Please take a moment to complete the online evaluation form.
FACT reviews the evaluations on an ongoing basis. When necessary, FACT committees (Education, Standards, Accreditation) investigate specific complaints from applicants, inspectors, and FACT staff.
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Commendable Practices
Inspectors are encouraged to identify commendable practices of any organization that may benefit other cell therapy programs or cord blood banks. By submitting commendable practices, you help:
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Motivate your peers,
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Highlight improvements in performance,
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Encourage high standards and reliability, and
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Create solutions for problems.
There are many forms of commendable practices, such as charts, forms, checklists, maps, presentations, processes, policies, and procedures.
Upon permission from the director, submit your commendable practice(s) to the FACT office. If you identified a commendable practice during the on-site inspection but did not have time to obtain permission from the director, submit the name and process of the commendable practice to the FACT Accreditation Office. FACT staff will contact the facility to obtain permission to use the commendable practice. The documents will be reviewed for inclusion in FACT education initiatives including webinars, workshops, publications, and the Quality Handbook.
