How Do Hospital Inspections Work? FAQ for Facilities
During hospital inspections, facilities undergo thorough evaluations to ensure they’re complying with state and federal regulations. Inspectors from governing and accrediting bodies assess key areas of safety and quality, taking the time to review documents, tour facilities, observe care, and interview staff. This process helps enforce standards that keep patients safe from harm.
As a facility leader, knowing what to expect during an inspection is the first step to improving regulatory compliance. In this article, we’ll answer some of the most frequently asked questions about this process to help you stay informed and prepared.
Who Does Hospital Inspections?
First and foremost, you may be wondering who inspects hospitals. There are actually three main types of organizations that can carry out a hospital inspection:
- Federal agencies, like the Centers for Medicare and Medicaid Services (CMS), establish and enforce federal care regulations.
- State agencies, such as health departments, ensure hospitals are complying with state laws in addition to federal ones.
- Accrediting bodies, including professional organizations like the Joint Commission (JACO), assess facilities based on key criteria for accreditation.
In some states, certain types of inspectors may also need to be certified. For example, individuals in California who want to become a Department of Healthcare Access and Information Inspector of Record (HCAI IOR) must complete an HCAI IOR application and pass an exam. This grants them a OSHPD inspector certification and qualifies them to inspect the architectural safety and quality of a hospital.
How Are Hospitals Inspected?
The specifics of this process will largely depend on the governing or accrediting body conducting hospital inspections. JACO in particular maintains a comprehensive readiness checklist to help facilities prepare for a visit from their team. CMS also outlines their inspection protocols in their State Operations Manual.
In general, though, an inspector or a team will visit a facility and review them based on established areas of quality and safety. This can include anything from infection control practices to emergency preparedness protocols.
However, facilities aren’t inspected by all existing governing/accrediting bodies. CMS only inspects facilities participating in CMS programs, such as nursing homes. Other types of accreditation are voluntary (though highly encouraged to demonstrate compliance). So, facilities will only be inspected by organizations if they’ve opted into their accreditation process.
Every How Many Years Must a Hospital Be Inspected?
How often hospitals are inspected will vary by agency/organization. We’ve outlined the frequency of inspections for some major federal governing/accrediting bodies in the table below.
| Governing/Accrediting Body | Inspection Frequency |
|---|---|
| Centers for Medicare and Medicaid Services (CMS) | Every 3 – 4 years |
| The Joint Commission (JACO) | At least once every 36 months |
| Accreditation Commission for Health Care (ACHC) | Every 3 years |
| Utilization Review Accreditation Commission (URAC) | Every 3 years |
| Center for Improvement in Healthcare Quality (CIHQ) | Annually |
| Community Health Accreditation Partner (CHAP) | Every 3 years |
| The Compliance Team (TCT) | Every 2 years |
Facility leaders should also refer to their local health department for more information on state-based inspections. For example, guidelines for Texas hospital inspections can be found on the state’s Health and Human Services (HHSC) website.
How Often Should Hospital Policies and Procedures Be Reviewed?
According to CMS and JACO, facilities should be reviewing their policies and procedures at least once a year. However, some events may warrant more frequent updates, such as regulatory changes, incidents and emergencies, or the adoption of new technology.
What Happens if a Hospital Fails an Inspection?
If a hospital violates any essential safety or care standards, it could fail an inspection. Some governing/accrediting bodies will work with hospitals to create a corrective action plan that addresses pertinent issues. But, if these issues are ignored, facilities may face more severe consequences such as:
- A loss of federal funding
- Accreditation revocation
- Suspension of operations
- Fines, jail time, or other legal proceedings
The Association of Health Care Journalists (AHCJ) also maintains an online repository of all federal inspection reports. This means that any notable deficiencies become public record, which can ultimately impact a facility’s reputation and ability to attract patients.
How Can Facilities Better Prepare for Inspections?
Hospital inspections may sound stressful, but with proper preparation, you can make the process go as smoothly as possible. Here are three strategies that can help your facility get ready for future inspections.
Stay Up-To-Date on Safety and Quality Standards
State and federal regulations can change frequently, and ensuring your facility reflects the most updated standards is crucial. Consider establishing a compliance team that’s responsible for regularly reviewing and adopting standards from government and accrediting bodies.
These organizations typically publish and maintain helpful guidance documents to make the inspection process as transparent as possible. Take advantage of these resources to ensure that there are no surprises when it’s time to get reviewed.
Conduct Internal Audits
Being proactive and scheduling self-assessments can help your staff address issues before an inspection. Hospital leaders can utilize existing accreditation checklists to conduct regular, internal audits. Beyond preparing your facility for inspections, this is also an effective way to maintain high quality care and keep your patients safe from preventable incidents.
Maintain Accurate and Updated Records
Thorough documentation and record-keeping is a fundamental part of the inspection process. If a team from CMS or JACO visits your facility, they will expect you to have relevant documents readily available for them. This can include things like staff credentials and training records, or incident reports and procedure manuals. So, it’s important to make sure that any documents demonstrating your compliance to local and federal regulations are well-maintained.
Is Your Facility Equipped to Maintain Compliance?
Hospital inspections help enforce regulatory standards, but they shouldn’t be the sole driver of your facility’s commitment to excellence. Looking for ways to maintain these standards every day? Get dozens of expert-written, healthcare management insights — all at no cost to you.