Virtual Inspections Lead to Accreditation Process Improvements

Posted in :: 2021 Volume 4, Uncategorized :: Wednesday, July 14th, 2021

By Suzanne Birnley, MS, MBA, FACT Accreditation Services Manager

It has been a very busy few months at FACT between the implementation of virtual inspections and publishing the eighth edition of the FACT-JACE International Standards for Hematopoietic Cellular Therapy Product Collection, Processing, and Administration.  These developments have led to some changes and improvements to the FACT Accreditation Process.

  1. Although initially developed for virtual inspections, some changes to submission requirements will continue to be part of the accreditation process moving forward. All applicant programs and banks are now required to submit additional documentation in preparation for their FACT inspection. For applicants currently waiting for their inspection to be scheduled, these documents can be uploaded in the FACT Accreditation Portal Document Library under the Virtual Inspection Documents tab.  These documents are expected to be submitted a minimum of 4 weeks prior to the inspection. These additional submissions have been included with the Eighth Edition Hematopoietic Cellular Therapy (HCT) Compliance Application, and will be included in other Standards as new editions are published. These include:
    • A copy of all policies and Standard Operating Procedures referenced in the Quality Management Plan.
    • The most recently completed Annual Report on the Effectiveness of the Quality Management Program.
  1. Whether for a virtual inspection or on-site, beginning July 1, 2021, all programs are required to use OneNote or the equivalent to organize documents for their inspection. This can be accomplished in several ways:
    • Use the OneNote template provided by FACT.
    • Use a software developed within the organization or a commercially available software.
    • Use the FACT Self-Assessment Tool or checklist from your completed application in the FACT Accreditation Portal, and add additional columns for links to documents and information regarding where to find documentation of compliance for each standard.
    • For on-site inspections, use the binder method. Match each standard to the documentation of compliance in paper form, all organized by standard in three-ring binders.
  1. For virtual inspections, beginning July 1, 2021, all programs are required to use a document camera to display documentation that exists in paper format. This is particularly important in collection or processing facilities that use paper records.

Finally, it is very important that inspectors have access to any updated documents, especially if the Compliance Application was completed a year ago.  FACT Accreditation Coordinators will send Requests for Information (RFIs) to update documentation known to be out of date, such as medical licenses and continuing education.  It is your responsibility to let your coordinator know if there are any other policies or SOPs that were submitted that have since been revised.  If inspectors do not have access to these documents, it is a risk that they may not see evidence of compliance, resulting in deficiencies cited on the Accreditation Report.

FACT greatly appreciates the hard work of the inspectors and applicants as we transition through this challenging time.  We do intend to return to on-site inspections as soon as it is safe to do so.  We are actively seeking and welcoming feedback on both the virtual inspection process and these process changes.  If you have any questions or concerns, please contact your Accreditation Coordinator or the Manager of Accreditation Services, Suzanne Birnley.