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5 Reasons why Clinical Staff Fail during site inspections.

Updated: Jul 31, 2023

pink pather getting blood pressure checks

Keeping your clinical staff accountable is tough. They are human, after all. With that in mind, it’s no surprise that the same people who work so hard to deliver exceptional patient care on a daily basis occasionally let their guard down during a site inspection—or any other operation moment for that matter. This is why keeping a watchful eye on your clinical staff is essential to maintaining high standards of quality and safety, not just during site inspections but also on a day-to-day basis. Whether you’re managing a team of medical assistants, nurses, or another set of hidden heroes within your organization, getting the right people in the right roles is key. Keep reading to discover five reasons why clinical staff often fail during site inspections and how you can help them succeed next time around.

Staffing is off

Depending on the type of inspection, the inspector may review the staffing plan to ensure it accurately reflects the patient census and acuity level. This information is used to determine whether staff members are meeting the standard of one staff member for every two patients or if there is a need for additional staff members to be present at any given time. Whether your team is caring for patients in an ED, OR, or an LTAC, staffing issues can create significant risk for an already complex operation. Although it may seem obvious, before an inspection occurs, be sure that staffing levels are accurate. In addition to staffing issues, be sure that your staff members are properly qualified for the position they’re in. For example, if there is a critical care RN on staff, but no patients on the unit require that level of care, the nurse may be bored or frustrated. This can lead to care issues. Once an inspection is underway, it’s common for staff to start rearranging rosters, moving key staff members to where they are needed most and adding additional staff members as needed.

Equipment is broken or not functioning correctly

Equipment issues are a major concern during an inspection. During a site visit, inspectors often use a pre-designed checklist to walk through all of the pieces of equipment found on the unit. Your team may be accustomed to repairing or replacing a piece of equipment should it break, but an inspector may not be aware of the issue and therefore may not document it. If a piece of equipment malfunctions and is not repaired, documented, and is not corrected, there is a real possibility that an inspector may cite the unit for it. The same applies for items that are not functioning correctly. There are a variety of ways to prevent equipment issues from occurring. First and foremost, regularly schedule preventative maintenance on all pieces of equipment. Beyond that, be sure to keep equipment inventories up to date and in a centralized location so that your team can easily locate and document any issues with equipment.

Documentation is lacking or inaccurate

In any healthcare setting, documentation is king. It holds staff members accountable for their actions and provides a trail of evidence in the event of a medical error. It also serves as an essential communication tool between staff members. Unfortunately, there are times when documentation is either not being completed at all or is not being completed correctly. This can happen when a staff member is new to the profession or is simply too busy to properly document everything that is happening on a given shift. The importance of accurate and complete documentation cannot be overstated. It’s the single most important tool in any hospital’s efforts to prevent medical errors and protect the privacy of patients. Unfortunately, at the time of an inspection, your staff members may be so focused on providing great patient care that they are not documenting correctly or at all. If this happens, it can lead to major issues during the inspection, including citations for incomplete or inaccurate documentation.

Mistakes were made (and now there’s no record of them)

A site visit is not the time to try out new techniques or procedures, especially when it comes to patient safety and care. Unfortunately, in the midst of trying to get through the shift, clinical staff can make mistakes and not document them. While mistakes are inevitable in any profession and should be expected, if the mistake is significant enough, it needs to be documented. A mistake that is not documented leaves no trail of evidence that it occurred, and as a result, there is little to no accountability for it. This can lead to a citation and can cause major problems for your team, the department, and even the hospital as a whole. The best way to prevent mistakes from happening in the first place is to create a culture of quality and safety. This includes creating a system of checks and balances within your clinical areas. In the event that a mistake is made, it must be documented. This is essential not just for the safety of your patients but also for the safety of your team members.

Your expectations are unclear

If there is one thing that all inspectors look for, it’s that clinical staff are meeting the standard of care. This standard can be outlined in your facility’s policies and procedures or in the state laws where you operate. In some cases, it may be a little from both. Regardless of where your standards of care come from, your clinical staff must know what is expected of them. If your clinical staff members don’t know what is expected of them, it will show during an inspection. Be sure that your clinical staff members understand your expectations for them, not only in general but also on a shift-by-shift basis. This can be achieved through frequent one-on-one meetings with each staff member, departmental meetings, or some other method as long as it happens frequently enough that everyone is on the same page.

Wrapping up

Clinical staff are under a tremendous amount of pressure. Not only do they have to care for patients, but they also have to work within the confines of strict quality and safety standards. In order for clinical staff to meet these standards and succeed during site inspections, they need support. And, like any other profession, they need to be held accountable when they don’t meet those expectations. Your team is counting on you to help them succeed. Don’t let them down.

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