Conduct

During an inspection, personnel are generally very sensitive to an inspector’s behavior and comments. Your conduct during an inspection speaks volumes about FACT and about you.

 

Be sensitive to the staff’s workload on the day of the inspection. Safe patient care is obviously the priority. If you feel that this is becoming a concern you should request that an individual staff member be assigned to deal with inspection issues. You can then work with him/her to coordinate the best time to tour the facility and meet with other staff if necessary.

 

Simple things such as politeness, a smile, and constructive suggestions can make a big difference to the inspection process. Applicant personnel are colleagues and the inspection process is supposed to be a collegial and helpful experience, not punitive or condescending.

 

It is natural that, as a professional of long standing, you will have preferences for how to comply with a standard. Please remember, there are many ways to achieve compliance. As long as the method that the applicant uses satisfies the intent of the standard, it is acceptable (even if you personally prefer a different approach). Alternative approaches may be discussed as part of the ongoing educational efforts if the personnel understand these alternatives are not required.

 

Differences of opinion should be expressed in a constructive manner. Do not make derogatory comments about findings or express surprise at what you find. Use the inspection checklist and report to record your concerns. When you are uncertain if a particular standard has been met, record your concerns on the inspection checklist and in your report, collect pertinent documents, and return everything to the FACT Accreditation Office. The FACT Accreditation Coordinators will refer any issues requiring further evaluation to the FACT Accreditation Committee and/or FACT Board of Directors.

 

It is appropriate to discuss your findings with personnel on an ongoing basis throughout the inspection to provide them with an opportunity to provide supplementary information or documentation. Be careful, however, that the tone of these discussions are accurately reflected in your exit interview. There should be no major surprises in the final report. Personnel occasionally complain they had no idea of the depth and scope of deviations until they received the final report from FACT, but instead had finished the inspection feeling they had done very well.

 

If you feel there are significant problems, or an applicant’s practices are very different from the majority of others', it is appropriate to suggest alternative approaches that may be more acceptable. Again, these suggestions should be given in a constructive manner and kept within the scope of the FACT Standards. If a staff member is not receptive to your suggestions or argues about a specific point, it is best to move on with the inspection and note the problem on your checklist.

 

The team leader should address any inappropriate inspector conduct at the time it occurs. If an inspector is not able to complete an inspection due to difficult personnel, or for any other reason, the FACT office should be contacted as soon as possible and the details of the issue should be included in the inspector’s evaluation of the inspection.

 

It is desirable to praise personnel for things that are done particularly well. This can include asking them for permission to copy SOPs, labels, or other documents for your own use. The inspection is intended to be collegial and to raise quality as a whole, so this type of activity is an acceptable part of the process. Remember, due to confidentiality reasons you must receive permission from the applicant.

Always remember to be the best representation of yourself, your organization, and FACT.  An inspector must strive to maintain his or her composure during the entire inspection.