Editor’s Note: This article originally appeared in the January/February 2025 issue of Radiology Management and is being republished with permission.

The thought of a visit by a regulatory body can be stressful — even when it is scheduled, versus an unannounced survey or inspection. The key to a successful regulatory visit is preparation. Give yourself plenty of time to properly prepare for a visit. A well-organized and thoughtful preparation period, well ahead of the anticipated visit, will put you at ease and enable you to perform calmly during the actual visit.

First, find a list from the regulatory body of things they will request. If that is not available, then find an old inspection list, or consult with a peer who has recently completed a similar survey. There are many resources available if you know where to look. For instance, your state agency may send you a notification for a scheduled survey a few weeks before the date of the visit, with a checklist attached of what they will review. But you may be able to find the checklist on their website much earlier than when they send it to you. Start working on this as soon as you are aware that the visit will occur.

If a large team will be involved in the survey, then appoint a facilitator who can create a spreadsheet to track assignments and completions. This will ensure accountability and make it a team effort rather than doing all the work yourself. Clearly define expectations, assignments, and due dates. Trust that the team will complete their assignments, but verify that they have done so. Hold regularly scheduled meetings with report-outs. Hold team members accountable for completing their assignments well before the visit.
Prepare anything ahead of time that you can anticipate a surveyor requesting. This includes consulting with often-overlooked teams such as facilities/maintenance, health information management (HIM)/medical records, and information technology (IT). Your IT team is especially important to include, as they can assist you when setting up conference rooms, computers, and audio-visual equipment. Do not stress yourself on the day of the survey (especially if it is unannounced) by having to worry about setting up a computer. Make sure your HIM team can quickly produce patient lists and your facilities team has room drawings, fire drill records, and occupancy permits readily available.

In my experience, leadership often fails to round in the area that will be surveyed. Get out of your office and walk through your department’s rooms! Perform targeted environmental rounding in the areas that will be surveyed. Even if the scope of the survey focuses on documentation or equipment, such as a Mammography Quality Standards Act (MQSA) inspection, it never hurts to identify trip hazards or dust prior to a regulatory visit. You may catch the surveyor on a difficult day, and they may notice a dust bunny and decide to look at other things in your environment. Ask leaders from adjacent departments to walk through your area. Fresh eyes often find items of noncompliance that you may overlook because you see it every day.

Prepare and include your employees well in advance of the anticipated visit. Let them know that a survey or inspection is coming and how they may be involved. Remind them that their work is crucial to providing safe and quality patient care. Explain the WHY behind the visit and how they can help your team be successful. Ask them questions that the surveyor may pose. Make sure you identify chart navigators who possess particular savvy when accessing your electronic medical record. Identify several of them in case the primary person is unavailable on the day of the survey.

Look over your equipment with your clinical engineer, checking inventory and maintenance stickers and records. One of our facilities was recently cited for missing a preventative maintenance report for a piece of equipment. We are certain that the maintenance was completed. However, it occurred during a transition between two clinical engineering companies and could not be located. Identify gaps in service such as these, and make sure you can find all equipment reports. Can your employees describe the appropriate process of taking equipment out of service that needs to be repaired? Once equipment has been repaired, ensure that there is a repair report available. Surveyors who identify documentation of broken equipment will ask what was done to fix it.

The inspector will ask for something that you do not anticipate, but getting the bulk of it ready ahead of time will certainly help.

During the visit, take good notes of everything the surveyor reviews, even if it is not something for which you are cited. Then share this list with your peers so they can properly prepare for their next survey. Also share your list with any of your consultants, such as a physicist group. This will enable them to keep current on items that surveyors are requesting, so they can properly prepare their clientele — including you.

Proper preparation is the key to a successful survey or inspection. There are so many known items a surveyor will request, making it possible to prepare for them ahead of time. This will allow you to be calm and ready to tackle any unanticipated items they request. Best of luck on your next survey or inspection — I know you will do great!