Responding to Inspection Citations is an Opportunity to Improve
The FACT Accreditation Committee reviews each inspection report and determines the outcome and required response from the accreditation applicant. A letter explaining the committee’s findings with instructions for documenting corrections, and the report listing the deficiencies and required responses, is sent to the organization following this determination. Each citation requires submission of the complete required response in the accreditation portal through the Request For Information (RFI).
Complete responses must include:
- Explanation of correction.
- Evidence of implementation.
- Supporting Standard Operating Procedures (SOPs) with changes highlighted.
- SOP approval documentation (signatures and date).
- Training documentation.
- Other identified documentation.
Each identified issue is an opportunity for improvement. The response must include an explanation of the correction and demonstrate how the applicable standard is met. Keep in mind that the reviewer of the submission will be less familiar than you with your organization’s operations or document control system. Walk the reviewer through each step in your process and identify where to find the supporting information in the submitted documents (e.g., list the page number and section or highlight the information). Ensure responses do not include Protected Health Information (PHI).
If you feel your process is sufficient or was misinterpreted during the inspection, explain your process, and submit supporting documentation demonstrating that it was in place during the time of the inspection.
Complete submissions must include a thorough explanation of correction and clearly marked supporting documentation to expedite review. The Applicant Response Template includes response examples. Once all citations have been adequately addressed, accreditation will be awarded.
FACT Announces Return to In-person Inspections October 1, 2022
Sarah Litel-Smith
Supervisor, Accreditation Services
FACT is excited to announce the return of in-person on-site inspections beginning October 1, 2022. Virtual inspections for renewal applicants were implemented in 2020 in response to the COVID-19 pandemic. While these virtual inspections have generally been successful as an interim measure, there have been some challenges and more delays than anticipated.
A recent survey of active inspectors indicates that most are comfortable with travel, at least domestically; their institutions permit travel; and applicant organizations are able to accommodate inspection teams. The return to in-person inspections will allow more expeditious inspection scheduling and facilitate much needed inspector trainee participation. The 40 new inspectors who completed an Inspector Training Workshop this spring at the ASTCT, ASFA, and ISCT meetings are anxious to complete their required trainee inspection. Please volunteer to be a mentor if you are an inspector and welcome a trainee inspector when your program schedules its on-site inspection.
Virtual inspections already scheduled through the end of September will be performed virtually as planned. If deemed necessary to protect the health and safety of inspectors, staff, and patients, or in response to other restrictions, FACT may conduct additional virtual inspections as needed. Contact your Accreditation Coordinator or FACT at fact@factglobal.org, or 402.920.7001, if there are any concerns related to the next on-site inspection.
Virtual Inspections Lead to Accreditation Process Improvements
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.
- 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:
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- 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.
- 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.
- 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.
Learning from Each Other: Accredited Organizations’ Advice for Preparing for FACT Inspections (Part 3)
By Stacy Freeburg, FACT Accreditation Coordinator
How do you maintain audits, various consent forms, and other documentation?
Richard Makin, Immune Effector Cell Quality Manager, NSW Health Agency for Clinical Innovation with The Children’s Hospital at Westmead Blood and Marrow Transplant Service
Our quality management system, Q-Pulse, has been fantastic for maintaining audits, documents, non-conformances, supplies, equipment, and now training courses. We are a central system overseeing 2 pediatric FACT-accredited sites and 12 nationally accredited sites (National Association of Testing Authorities, Australia/National Pathology Accreditation Advisory Council [NATA/NPAAC]). Without this tool, we would not exist. It automates actions, creates workflows, and emails notifications. I really like how easy it is to modify drop downs to meet our requirements without information technology upgrades or database changes. It is also very intuitive for staff, which makes training and day-to-day use very easy. I used to work for the national body, NATA, and I saw a lot of very complicated software packages-at accredited sites. Many were not well used!
Melissa Henson BS, RN, OCN, Manager, Cellular Therapy and Leukemia Program, The Blood and Marrow Transplant/Leukemia Program, Northside Hospital Cancer Institute
and Ashlee Holbein, RN, FACT/QI Coordinator, The Blood and Marrow Transplant Program at Northside Hospital
Maintenance of audits, consent forms, and labeling is assigned to various quality designees, as applicable. Our programmatic Standard Operating Procedures (SOPs) describe established processes for follow-up and reporting to ensure the audits are completed in a timely manner. SOPs dictate processes for consent updating and review. Check-off and time-out processes ensure labeling is completed per standards and regulatory guidance. The quality designees work with physicians, supervisors, and clinicians to maintain compliance with FACT standards impacting the daily duties of staff members. The integration into daily practice creates a quality-focused program, with built-in and evolving checks and balances throughout the program’s departments to ensure consistency of processes and procedures.
Share strategies for staying up to date on upcoming changes to the Standards and what tools you use to communicate those upcoming changes within your organization.
Richard Makin, Immune Effector Cell Quality Manager, NSW Health Agency for Clinical Innovation with The Children’s Hospital at Westmead Blood and Marrow Transplant Service
Generally, this is done via Q-Pulse. We have had specific training sessions across our network, which have focused on donor work-up, ISBT 128 labelling, and GMP requirements.
An Immune Effector Cell (IEC) Quality Manager focuses purely on IEC rather than both Hematopoietic Progenitor Cell (HPC) and IEC. This has assisted in developing IEC-specific SOPs and processes. This is such a growing area that I believe it needs individual attention.
Melissa Henson BS, RN, OCN, Manager, Cellular Therapy and Leukemia Program, The Blood and Marrow Transplant/Leukemia Program, Northside Hospital Cancer Institute
and Ashlee Holbein, RN, FACT/QI Coordinator, The Blood and Marrow Transplant Program at Northside Hospital
Monthly meetings are conducted to discuss regulatory topics, including any updates to the FACT Standards. Key personnel from the clinical, collection, and processing facilities participate in the monthly meetings. Consistent monitoring of the FACT newsletter and disseminating pertinent updates occurs during these meetings. Note, our programmatic SOPs outline how updates need to be conveyed to the program, reviewed with the FACT Program Director, and distributed to the program through an appropriate conduit based on the impact and urgency of the change.
Stacy Freeburg, FACT Accreditation Coordinator, FACT Accreditation
Maintain a spreadsheet or utilize OneNote or a similar tool that crosswalks the FACT Standards to your SOPs. FACT provides an Excel download of all standards and related questions, called the Self-Assessment Tool, in the portal that can be used to prepare for the accreditation process. If a new edition of Standards is finalized during the organization’s accreditation cycle, organizations can use the crosswalk FACT provides to update its internal crosswalk to SOPs (available on the FACT website).
For additional information, download and view the educational recording, QM Series 8: The Document Control Process From Start to Finish (and Back Again!) (FACT), September 13, 2017.
Thank you to the following contributors for sharing their tips and lessons learned from their experiences at a FACT accredited program:
Melissa Henson BS, RN, OCN, Manager, Cellular Therapy and Leukemia Program, The Blood and Marrow Transplant/Leukemia Program, Northside Hospital Cancer Institute
and Ashlee Holbein, RN, FACT/QI Coordinator, The Blood and Marrow Transplant Program at Northside Hospital
Richard Makin, Immune Effector Cell Quality Manager, NSW Health Agency for Clinical Innovation with The Children’s Hospital at Westmead Blood and Marrow Transplant Service
Elisha Nixon, Quality Program Manager, Walter Reed National Military Medical Center, Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, The Henry M. Jackson Foundation
Learning from Each Other: Accredited Organizations’ Advice for Preparing for FACT Inspections (Part 2)
By Stacy Freeburg, FACT Accreditation Coordinator
FACT-accredited organizations voluntarily seek and maintain FACT accreditation via a rigorous process, demonstrating their commitment to quality and their belief that patient needs are paramount. Obtaining and maintaining FACT Accreditation is a major undertaking.
Recognizing that we are a peer-driven organization, we invited a few organizations who are currently FACT accredited to share their suggestions for how to maintain many of the documents required for FACT Accreditation.
How does your program organize various documents so that they are readily available, such as current licenses, specialty certificates, or CVs?
Richard Makin, Immune Effector Cell Quality Manager, NSW Health Agency for Clinical Innovation with The Children’s Hospital at Westmead Blood and Marrow Transplant Service
This is a challenge. For large education sessions that are renewable (e.g., Risk Management Program (RMP) training), we have started using the Training Courses module in our Q-Pulse quality management software. This allows for central management and electronic record keeping.
Melissa Henson BS, RN, OCN, Manager, Cellular Therapy and Leukemia Program, The Blood and Marrow Transplant/Leukemia Program, Northside Hospital Cancer Institute and Ashlee Holbein, RN, FACT/QI Coordinator, The Blood and Marrow Transplant Program at Northside Hospital
This information is reviewed on an annual basis to ensure documents are up to date and organized for each employee in our employees’ FACT folders. If updates are needed, the information is requested directly from the employee or obtained though administrative staff. The timing of the annual review of the employees’ FACT folders corresponds with our hospital’s annual employee evaluations. Copies of licensure and certificates for key personnel are stored in a shared electronic folder to allow access to those who may require it throughout the year.
How does your program compile and maintain the educational activities list?
Richard Makin, Immune Effector Cell Quality Manager, NSW Health Agency for Clinical Innovation with The Children’s Hospital at Westmead Blood and Marrow Transplant Service
For the last six to seven years, we have been providing a “BMT Masterclass”. The schedule of topics is based on the FACT requirements. This is a virtual presentation or prerecording. These are recorded and subtitled and placed on our website at https://aci.health.nsw.gov.au/networks/blood-and-marrow-transplant/resources. All members of BMT Nurses, Scientist, Physicians, and Pharmacists in New South Wales (NSW) and across Australia have access. We also run a “Introduction to BMT” session once a year, a scientific forum, and senior nurses’ day. We use a basic template for recording.
Melissa Henson BS, RN, OCN, Manager, Cellular Therapy and Leukemia Program, The Blood and Marrow Transplant/Leukemia Program, Northside Hospital Cancer Institute and Ashlee Holbein, RN, FACT/QI Coordinator, The Blood and Marrow Transplant Program at Northside Hospital
Our program utilizes the FACT Educational Activities Form throughout the program departments to document cellular therapy education on an annual basis. Key team members maintain their own educational activities form, and the form is part of the annual audit of the individual employees’ FACT folder.
Stacy Freeburg, FACT Accreditation Coordinator, FACT Accreditation
When I worked in direct health care, a sign-in sheet was provided for all internal training to document educational activities. Information gathered included training title, date and length of the training, title of the training, and attendees’ name. In addition, staff were expected to submit documentation of any external training to a central location. This information was compiled onto a word document for each staff member (similar to the FACT Educational Activities Form). The sign in sheets also provided documentation that the organization provided opportunities for staff for educational activities.
Staff also were required to update their educational activities in a system tied to the Human Resources department’s intranet. Information gathered included the activities’ titles and dates and length of training. Activities could be webinars, reading an article, etc. Staff were then able to print out a summary form. All staff were required to turn in a copy during their annual personnel evaluation, which demonstrated compliance with requirements and made it readily available for submission for accreditations.
Benefits of Documenting Educational Activities
Documentation is not only a way to document educational activities for FACT Accreditation, but can also be a resource for planning future training needs. To maximize the usefulness of educational activity records, it is important that they be up to date, organized for easy retrieval, and have a mechanism to for review. By reviewing the types of educational activities staff have attended, programs can determine what education is needed. For example, the program may wish to expand opportunities to include tumor board discussions, review of peer reviewed articles, or ensuring that staff have the opportunity to attend various professional conferences.
As noted above, gathering licenses and educational activities is challenging. Tying the submission to annual performance evaluations or having an annual audit to verify it is complete are two methods to avoid a panic when you need to submit the information.
Download the FACT Educational Activities Form
Learning from Each Other: Accredited Organizations’ Advice for Preparing for FACT Inspections
By Stacy Freeburg, FACT Accreditation Coordinator
FACT accreditation is the threshold for excellence in cellular therapy, including blood and marrow transplantation, immune effector cellular therapy, and cord blood banking. FACT-accredited organizations voluntarily seek and maintain FACT accreditation via a rigorous process, demonstrating their commitment to quality and their belief that patient needs are paramount. Obtaining and maintaining FACT Accreditation is a major undertaking.
Recognizing that we are a peer-driven organization and beginning to resume inspections, we invited a few organizations who are currently FACT accredited to share their suggestions for obtaining and maintaining FACT accreditation. In this article, we focus on improvements programs made to their accreditation preparation based on their experience.
What changes did you make after accreditation was awarded to make the next cycle a bit easier?
Richard Makin, Immune Effector Cell Quality Manager, The Children’s Hospital at Westmead Blood and Marrow Transplant Service
– A big one is START EARLY. When completing the Compliance Application, we try to get our documents as up to date as possible in the months beforehand so we do not make any changes when submitting documents. It is too hard to do in parallel and too time consuming. It is not really meeting the expectation of compliance either: documents and procedures need to be in active use when the inspectors come to assess.
– Conduct regular FACT meetings. We have monthly FACT meetings throughout the accreditation cycle on top of the quarterly large meeting where we summarize the majority of the quality system elements.
– We have found reviewing Immune Effector Cell data every 2nd Quarterly Quality Meeting useful. This has enabled us to get enough data on efficacy and outcome. It also gives us more time to drill down to the significance of results.
– The paediatric ANZCHOG (now TACTIC) annual meeting (Australia + New Zealand) has been a key meeting for reviewing patient outcomes. This is really well supported by our registry (Australasian Bone Marrow Transplant Recipient Registry), who provides sites specific reports. Each centre provides an overview of all their patients and treatments used. The meeting has expanded to include nurses, quality managers, data managers, pharmacists, and scientists in addition to the treating physicians. This is excellent for real-world data analysis, collaboration, and continuing education.
– The annual report of quality activities has been a very useful tool for quality improvement and has grown to many pages. Again, we need to start early as it takes a long time to compile.
– Our registry has been very helpful in working with us on benchmarking outcomes. When this became a requirement a few years back, we sat down and came up with a plan. Now they have standard database report with indications, transplant numbers, engraftment, GVHD, and survival graphs comparing other sites in Australia and New Zealand. This has helped a lot rather than analyzing ourselves.
Elisha Nixon, Quality Program Manager, Walter Reed National Military Medical Center, Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, The Henry M. Jackson Foundation
After our program identified significant deficiencies during our FACT inspection in October 2016, a new Quality Manager was brought on board to revamp the entire program. Processes within the administrative, clinical, and laboratory processes were all modified to a significant extent. Following re-inspection, our program was granted re-accreditation in March 2018. Failure was not an option, and a change in mindset helped staff recognize that every Request for Information (RFI) was an opportunity to improve to guide us towards success.
Three years later, we have successfully maintained a program following best practices within the organization. We strive for continuous survey readiness because we learned a very hard lesson. While falling hard is rough on everyone, learning from those mistakes and implementing solid processes helped our program become even better than we could have imagined.
Melissa Henson BS, RN, OCN, Manager, Cellular Therapy and Leukemia Program, The Blood and Marrow Transplant/Leukemia Program, Northside Hospital Cancer Institute and
Ashlee Holbein, RN, FACT/QI Coordinator, The Blood and Marrow Transplant Program at Northside Hospital
To demonstrate standard compliance for the inspector, each department maintains a shadow notebook to allow for an efficient and smooth review of evidence. The shadow notebook is comprised of tabbed sections of each standard applicable for a department, including a title page and any supporting documents behind the corresponding tab. During our past two accreditation cycles, our program found the shadow notebooks immensely diminished time spent paging through documents. The shadow notebooks eliminate the need to visit multiple sources, specifically in situations when a standard impacts more than one area of the program. A key factor for the development and organization of the shadow notebooks is consistent mock FACT inspections with physician leadership and individual department quality designees.
FACT mock inspections are scheduled with all program departments to provide a format to meet collectively to review all FACT standards. The collective review of the FACT standards allows time for brainstorming and discussion of standard implications across various areas of the program.
Do you have any example approaches for maintaining compliance with the various standards?
Melissa Henson BS, RN, OCN, Manager, Cellular Therapy and Leukemia Program, The Blood and Marrow Transplant/Leukemia Program, Northside Hospital Cancer Institute and
Ashlee Holbein, RN, FACT/QI Coordinator, The Blood and Marrow Transplant Program at Northside Hospital.
FACT standards are at the forefront of any discussion regarding updating a process or procedure. The first question is always, “What does the FACT standard say?” Daily, weekly, monthly, quarterly, and annual audits are used to ensure compliance throughout the accreditation cycle. Certain key standards are incorporated into quarterly programmatic quality improvement meetings to provide an overview of compliance to the program.
Richard Makin, Immune Effector Cell Quality Manager, The Children’s Hospital at Westmead Blood and Marrow Transplant Service
Our routine audit cycle focuses on standard FACT topics and is expanded to assess the implementation of new requirements. When new standards are published, we do a gap analysis against our current SOPs and processes. We do this informally when FACT circulates the drafts and formalize when active.
In summary:
Continuous readiness is the goal of all organizations, which means that 1) actual practice matches what is in the approved policies and procedures and 2) there is a mechanism, such as an audit, to verify implementation. It is critical that programs build systems that assure that compliance can be maintained with accreditation standards on an ongoing basis. A common theme from the suggestions is including the FACT Standards as part of discussions on a quarterly, monthly, and daily basis. Regularly looking at the FACT Standards while discussing new processes and procedures allows an organization to address issues and act on them in a timely manner.
Tools available on FACT’s web page:
When a new edition of the Standards is implemented, the FACT web page at http://www.factwebsite.org/standards/ is updated to include a summary of the changes from the previous edition. Also posted on this site are updated documents such as document submission requirements and other self-assessment tools.
In the webinar, Using an Electronic Platform for Accreditation Preparation and Continuous Readiness, presenters provided step-by-step instructions on how to build a OneNote FACT e-binder and organize evidence to be used for continuous readiness or as a platform to deliver evidence to the FACT inspection team. The webinar is available at http://www.factweb.org/forms/store/ProductFormPublic/using-an-electronic-platform-for-accreditation-preparation-and-continuous-readiness-webinar.
Update on FACT Virtual Inspections
FACT has initiated its accreditation renewal process with virtual inspections starting with two programs whose renewal inspections were delayed in March 2020 due to the COVID-19 pandemic. By all accounts, the virtual inspections were successful! The applicant programs were well prepared, the processes were generally effective, inspectors were able to verify compliance with Standards, and both inspectors and program staff continued to learn throughout the process. As a result, FACT is now scheduling virtual inspections for additional programs whose inspections were delayed, followed by those who were in the process of scheduling inspections when the pandemic started. Program Directors, Quality Managers, and primary contact persons at eligible programs should expect direct communications from their FACT Accreditation Coordinators to begin this scheduling.
The FACT Virtual Inspection Task Force developed this virtual process over the past several months to closely mimic the in-person experience to the extent possible, including submission of the same documents to the FACT Accreditation Portal in advance and review of these documents by the Inspection Team. The FACT Accreditation staff participated in training the applicants and inspectors in the technical skills required for the virtual process. Members of the Task Force volunteered their own programs to serve as pilot programs for the virtual inspection process, and volunteered themselves to be the first inspectors. The two pilot programs included clinical transplant and immune effector cellular therapy sites, bone marrow and apheresis collection services, and cellular therapy product processing facilities with minimal and more than minimal manipulation processing. Each pilot inspection took place over two days using individual secure Zoom calls, during which the inspectors were able to view documents and pre-recorded facility video tours and interview various members of the applicant program (including nurses; advanced practice professionals; pharmacists; ICU, ER, and Radiation Oncology staff; data managers; and clinical research associates. Program staff shared records, minutes, policies, SOPs, and other documentation by sharing a computer screen for electronic or scanned documents or by using a cell phone or document camera for other types of documentation such as paper files, logs, and records.
Task Force members and FACT staff observed portions of these pilot inspections and are currently assessing the processes. At least two important themes have been identified to date. First, it is important for the applicant program to be well organized with documentation prepared in the order of the FACT Standards. Use of Microsoft OneNote or other electronic programs to link program documentation to a specific FACT Standard is very helpful to allow efficient location and display of relevant policies and SOPs. Once created, this tool can be used to continuously update documentation and maintain inspection-readiness through the accreditation cycle. Second, the inspection goal is to demonstrate implementation of required policies and SOPs through examples. Identification and organization of these patient records, meeting minutes, validation studies, audit reports, and other quality documents according to the specific standard facilitates demonstration of compliance. While neither of these concepts is new, the virtual process magnifies the importance of careful organization.
Additional details of the inspection process are available on the FACT Virtual Inspection Resource Center at: http://www.factwebsite.org/virtualinspections/. Numerous documents are available, including timelines, sample inspection agendas, applicant and inspector guidelines for the virtual process, organization tips, and technical information related to Zoom and document sharing methodologies.
As the next group of programs is ready for inspection, additional training will be held for currently active cellular therapy program inspectors. A full inspector training course for new inspectors that will include both the in-person and virtual inspection processes is planned for early summer. This virtual inspection process is intended for renewal applications only. Initial accreditation visits will be in person and will be scheduled when it is safe to do so and appropriate inspectors are available to travel. Virtual inspections for cord blood banks will begin this spring. New applicants for initial accreditation will require an in-person inspection that will be scheduled and fulfilled as appropriate inspectors are available.
FACT is grateful for the extra effort on the part of these pilot programs and inspectors. The Virtual Inspection Task Force includes members of the Cellular Therapy Accreditation Committee, the Inspector Development Committee, and the Board of Directors.
FACT Virtual Inspections in Response to COVID-19
FACT plans to begin virtual inspections this fall. There are many details to be finalized, however, the FACT Board of Directors has approved the plans outlined below. Thank you in advance for your flexibility and patience as we undertake this new process to protect the safety of our volunteer inspectors, personnel at accredited programs, and patients.
Eligibility for Virtual Inspections
Situations eligible for a virtual inspection include:
- Renewal accreditation inspections of clinical, apheresis, or cell processing programs applying independently or together as a hematopoietic cell transplantation program, including immune effector cells.
- Add-on service involving an existing accredited program (such as immune effector cells [IECs] or more than minimal manipulation processing).
- Reinspection of all or a portion of a program following Accreditation Committee review of an in-person inspection, provided at least one member of the original inspection team participates in the virtual inspection, and there were no citations related to the physical integrity of the location itself.
Situations not currently eligible for a virtual inspection, and for which an on-site inspection is required, include:
- Initial accreditation
- Addition of an entirely new service in a new space, such as a pediatric program at a Children’s Hospital being added to an existing accredited adult program in another facility or a new current Good Manufacturing Practices (cGMP)-compliant processing facility added to an accredited transplant program.
In general, inspections will be either virtual or on-site, not a mixture. There may be exceptions. For example, an add-on to an existing program that is in the renewal process could have a virtual inspection for the renewal portion and an on-site visit of only the add-on portion (e.g., a cGMP facility for IECs added onto an accredited transplant program).
FACT is also working toward resuming some prioritized on-site inspections where these can be done in compliance with state, local, and CDC guidance and within facility and inspector restrictions. This applies primarily to new applicants.
Prioritization of Virtual Inspections
Priority for virtual inspections will be given to cellular therapy programs whose on-site inspections were canceled, then to those who were in the process of scheduling when the on-site inspections were suspended in March 2020. Cord Blood Banks will begin virtual inspections slightly later.
All programs have been given an additional 6-month extension of their accreditation expiration dates as we resume inspections in this new way. This represents a total of a one year extension to the accreditation expiration.
Preparing for Virtual Inspections
Programs will receive direct individual communications regarding additional documentation that will be required either as an extra annual report or additional pre-inspection updates, depending on where they are in the accreditation cycle.
Please watch for communication from your FACT Accreditation Coordinator. You may contact your FACT Accreditation Coordinator for additional information and share this information with other appropriate individuals in your program, including apheresis and cell processing services. Your Accreditation Coordinator’s contact information can be found at http://www.factwebsite.org/About_FACT/FACT_Staff.aspx.
If you do not know who your coordinator is, contact Suzanne Birnley, Manager of Accreditation Services at suzanne.birnley@unmc.edu.
The Virtual Inspection Process
The platform for the interactive virtual inspections will be a FACT HIPAA-compliant ZOOM Healthcare account. There will be video tours expected, however, inspections will not be recorded. Video tours and additional documentation will be submitted through the FACT Accreditation Portal.
Cellular Therapy Program inspections will most likely occur over two days to allow both inspectors and program staff additional time to review and prepare additional documentation.
The Virtual Inspection Task Force is finalizing:
- The list of additional documents that will be submitted in advance.
- A list of documents that the program must be prepared to show to the inspector via ZOOM shared screen, which may include electronic documents such as SOPs, a portion of the EMR, or other scanned documents. Paper records may be shared via scanning or document or portable camera.
- A list of items that will be demonstrated via a video tour of each site.
- A proposed inspection agenda, including additional persons to be interviewed during the inspection, such as staff nurse, pharmacist, ICU / ER physician or staff.
Confidentiality of the Virtual Inspection
FACT has a Business Associate Agreement in place with each accredited and applicant program to cover confidentiality issues, including protected health information that may be viewed as part of the accreditation process, but is not recorded or retained by FACT or its volunteers. FACT’s legal counsel has determined that the current Business Associate Agreement is sufficient to safeguard the virtual inspection process. FACT will work with any institution individually if there are concerns. All FACT staff and volunteers annually sign Confidentiality and Conflict of Interest Agreements.
In addition, the virtual inspection process will incorporate practices to enhance confidentiality, such as requirement for a private room for the inspector to conduct the inspection and lack of recording of the inspection.
Frequently Asked Questions
In addition to questions directly related to accreditation, FACT continues to receive questions related to patients, donors, and other COVID-19 related issues. A Frequently Asked Questions document is periodically updated and is available on the FACT website. Topics include:
- Rescheduled inspections
- Renewal process
- Allogeneic transplant numbers
- Relocating transplant patients
- Deviations
- Care adjustments related to COVID-19
If you have further questions or concerns, please contact Dr. Phyllis Warkentin [phyllis.warkentin@factglobal.org or 402-559-6781], the FACT office (402-559-1950), or your FACT Accreditation Coordinator.
Other Resources Available:
ASTCT Resources
WMDA Resources
Centers for Disease Controls
World Health Organizations
NMDP/BeTheMatch
FACT Inspections Amid the Pandemic
FACT is eagerly anticipating resumption of accreditation activities. In March 2020, FACT suspended on-site inspections and extended all accreditation deadlines and expiration dates by six months due to the COVID-19 Pandemic. During this time, FACT staff have continued to review submitted applications and responses, prepared and presented educational webinars, and facilitated the vital committee work in standards development, accreditation, quality, clinical outcomes, data audits, education, immune effector cell initiatives, and international accreditation support.
Although the pandemic is not over, some travel has resumed, and some institutions are opening elective procedures and in-person visits. A FACT Task Force will determine the best approach to resumption of on-site inspections. Options include virtual inspections, in-person inspections associated with limited travel, or a combination of methodologies. Factors to be assessed include inspector availability, inspector ability to travel, openness of institutions to non-essential individuals, and characteristics of the applicant program such as prior accreditation and the time remaining until accreditation expiration. Inspector availability and on-site options are being assessed through a survey distributed to inspectors and Program Directors. FACT will publish periodic updates related to inspections through the Newsletter and email communications.
FACT-JACIE Stepwise Accreditation Program
A joint FACT-JACIE Stepwise Accreditation program has been developed to globally improve hematopoietic cell therapy quality, enhance safety for donors and patients, and make transplantation accessible to qualified patients. The approach consists of three incremental steps to accreditation to enable programs to focus on their quality systems first and ensure operations for patient and donor safety. The second phase builds on the established foundation to develop a complete quality management program and provide for efficacious care. The final step evaluates the effectiveness of the quality program, ensures reporting to the appropriate regulatory and accrediting agencies, and evaluates clinical outcomes.
Twelve blood and marrow transplant (BMT) centers in Latin America were identified to participate in the initial pilot program.
The first transplant center to be inspected under the FACT-JACIE Stepwise Accreditation Program has offered to share their first-hand experience with the process. While FACT’s standard policy is to not release this information prior to completion of the accreditation process, the program may elect to release results at their own choosing. It is inspiring to hear of the hard work and accomplishments of new programs embarking on their accreditation journey.
The new joint accreditation process also provides an opportunity for continuing education for both applicants and inspectors. At times, subtle differences in interpretation of FACT-JACIE Standards can occur. Professional discussion about potential interpretation is always interesting, educational, and useful to make the next edition of Standards more clear. It also points to the critical role of the Accreditation Committee in maintaining consistency in interpretation and in management of the decisions related to compliance.
The BMT Program of the Private Universitary Hospital of Córdoba in Argentina, was the first centre in Latin America to be inspected as part of a pilot group participating in the FACT-JACIE Stepwise Certification Program. Patrica Abichaín, Quality Manager, explains the preparation process and the inspection that took place on November 20-21.
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First joint FACT-JACIE Inspection in Latin America: our experience.
The “Programa de Trasplante de Médula Ósea del Hospital Privado Universitario de Córdoba, Argentina”, member of the Latin America Bone Marrow Transplantation (LABMT) cooperative group, was the first centre in Latin America to be part of the pilot group in the FACT-JACIE Stepwise Certification Program. This project is an innovative proposal for centers in this geographic and economic region to provide a pathway to achieve full accreditation through a step-by-step process.
To be selected for “The Stepwise Certification Program” meant a great challenge for us. It started in July 2017, when we sent the Application Form; a few months later, we received the documentation that should be completed, including the inspection checklist, which became our working tool during several months.
In order to move forward in this process, it was a great advantage to be a joint program (Collection Unit, Processing Unit, and Clinical Unit working together in a single location), strongly motivated by the Program´s Director, who became the leader of a working team formed by the units’ directors, representatives of the units and members of an external company of Quality Consulting. The first task was to perform an internal audit to assess our situation, design a workflow, and finally start making some changes in our way of working.
Completing the inspection checklist was really a huge effort. We spent almost 3 months working on it to achieve the first version that we submitted on March 16, 2018. Fortunately, we had support from FACT and JACIE, who helped us to understand the Standards and demonstrate evidence of compliance.
In the meantime, we began to build a “Quality Management System”. The first step was to name a Quality Manager who wrote a Quality Plan in collaboration with the units’ representatives. This group, our Quality Committee, defined measurable outcomes, performed internal audits, implemented validation plans for critical processes in different areas, worked together with the institution’s Human Resources Management in creating job descriptions for keys positions, adopted both the institution’s System for Document Control (knowing with certainty the importance of this chapter in the scaffolding of a Quality Management System for both the hospital and the transplant program), and developed an Incident Reporting System encouraging personnel to know and use them; involved the institutional Bioengineering section for control and maintenance of critical equipment, as the most relevant items. To accomplish this challenge, it was extremely useful to have access to the FACT Quality Handbook, the JACIE Quality Management Guide, and documents kindly provided by generous centers from Europe and the United States.
In each unit, Standard Operating Procedures (SOPs) were written, discussed, reviewed and implemented. All of them are first version and we will update them in the near future adopting guidance provided by JACIE and FACT inspectors. Besides writing SOPs, we tried to re-organize the activities with regards to human resources, facilities and equipment. We also introduced simple statistical tools in order to follow-up on our measurable outcomes.
During this time, we reviewed and updated the checklist to find the best evidence for each standard. Closer to the inspection date, we multiplied our efforts to be on time!
The onsite inspection took place on November 20–21, 2018 and was performed by a team of four international inspectors (United States, Spain and Norway) from FACT and JACIE. The inspection was performed in a rigorous and friendly way. To note, this was the first time that inspectors of both accreditation organizations worked together on a joint inspection. We could appreciate subtle differences in the interpretation of some standards, which, in turn, enriched the inspection experience in our opinion. Additionally, we took advantage of the exchange of opinions among colleagues in the field of transplantation, which was very useful for us.
At the end, the closing remarks were extremely helpful; we took note of our strengths and our weaknesses, mostly in Quality Management. We are now waiting for the Inspection Report, but in the meantime, we continue working in accordance with the inspectors’ observations and non-conformities found during inspection.
In summary, this was a great experience. We learned that the most challenging thing was to achieve staff motivation and cultural change, but the inspection itself gave us strong encouragement to continue working in order to achieve the FACT-JACIE First Step Certification in the next few months.
Selection of Cord Blood Collection Sites for FACT Inspections
By Cathy Talmadge, FACT Accreditation Services Supervisor
Cord blood collection sites are selected for inspection based on specific variables in order to evaluate compliance with the NetCord-FACT Standards. Cord blood banks should be aware that sites they consider to be “non-fixed” may be inspected during the next FACT inspection depending on the site’s ongoing responsibilities and number of collections performed.
In order to prevent issues upon scheduling the inspection, FACT recommends that cord blood banks inform their non-fixed collection sites that an on-site FACT inspection may occur. The following information may be helpful to non-fixed collection sites who are unfamiliar with FACT accreditation and processes:
- The mission of FACT is to improve the quality of cellular therapy through peer-developed standards, education, and accreditation for the benefit of patients. WMDA-NetCord’s mission is to support, promote, and enhance safety, efficacy, and availability of international exchange of cord blood units and to harmonize global practice of cord blood banking and supply. Accreditation is achieved by demonstration of compliance with the current edition of the NetCord-FACT International Standards for Cord Blood Collection, Banking, and Release for Administration (the “Standards”). The Standards have been developed to promote quality medical and laboratory practices throughout all phases of cord blood collection, banking, and release for administration to achieve consistent production of quality placental and umbilical cord blood units for administration. They are developed by world-renowned experts in the field including clinicians, collection professionals, laboratory scientists, technologists, and quality experts. The Standards are based on published medical literature, when available, and accepted scientific theory and expert consensus. The Standards define minimum requirements to reach a level of quality worthy of accreditation and allows flexibility in methods/processes to meet requirements.
- To be eligible for accreditation, a cord blood bank must have processes in place to meet all of the Standards, whether the activities are performed internally or by contract with another facility. The inspection and accreditation process is summarized on the FACT website and includes an on-site inspection of the bank, cord blood collection sites, and cord blood processing and storage facilities. Because they perform a critical step of the cord blood banking process, facilities that collect cord blood units for an applicant bank are inspected during the accreditation process. Collection sites are selected depending on a number of variables to allow verification of compliance of all processes used by the bank.
- At least one staff member of the cord blood bank pursuing accreditation accompanies the inspector during the on-site inspection of collection sites. The FACT inspectorate consists of experienced individuals active in the field who have a strong and vested interest in ensuring the availability of the highest quality cord blood units for administration. The inspectorate includes transplant physicians, cord blood bank directors and medical directors, cord blood collection directors, and cord blood processing facility directors. Inspectors complete an inspector training course, pass a written exam, participate in at least one inspection as a trainee inspector, and participate in ongoing education.
- The cord blood bank will work with the selected collection sites during the preparation for inspection, including document submission, compilation of evidence, and scheduling the inspection. Any deviations noted during the inspection will be reviewed by the FACT Accreditation Committee comprised of leaders in the field of cord blood banking. The cord blood bank will be provided with the committee findings and is responsible for correcting any deficiencies identified. FACT encourages collection sites to maintain close communication with the cord blood bank as they prepare for an inspection.
Requirements for Qualifying Third-Party Manufacturers of Cellular Therapy Products Regulated Under U.S. INDs or BLAs
In light of the recent licensing of immune effector cell (IEC) products in the United States, this is an opportune time to continue education regarding third-party manufacturers in general. The manufacturing process for many novel cellular therapy products, including research and licensed cellular therapy products, involves multiple entities: holders of Investigational New Drug (IND) applications for research or Biological License Applications (BLA) for licensure, collection facilities, and processing facilities. Clinical units may be involved with one or more of these facilities.
There are three main responsibilities when third-parties are involved in the manufacture of a research or licensed product: verify regulatory oversight, qualify the vendor or service provider, and define responsibilities.
Though many questions from organizations regarding these requirements are specific to IEC processes, the information below can also be used as guidelines for other types of cellular therapy products.
Verify Regulatory Oversight
- The participating manufacturer (e.g., collection or processing facility) is responsible for verifying that the contracting entity for whom it performs services possesses an approved IND or BLA.
- The Clinical Program is responsible for verifying the manufacturer responsible for the entire manufacturing process (e.g., a commercial manufacturer) possesses an approved IND or BLA.
Qualify the Third-Party Manufacturer
- The IND or BLA holder is responsible for verifying that any facility performing a step of manufacturing complies with GMP and GTP requirements as applicable (see 21 CFR 1271.150(c)(1)(iii)).
- If the IND or BLA is held internally by a FACT-accredited facility, then the facility must perform this qualification and provide documentation to FACT inspectors.
- If the IND or BLA is external, i.e., held by a third-party investigator or manufacturer, this qualification is outside the scope of FACT accreditation and the FACT-accredited facility is not required to provide documentation of this type of qualification to FACT inspectors.
The participating manufacturer must participate in site visits from the IND or BLA holder and provide the level of service required of that entity, including compliance with GMP and GTP requirements as applicable. FACT-accredited facilities that participate in manufacturing for external IND or BLA holders must provide FACT inspectors evidence of complying with these requirements as required by applicable laws and regulations.
- The Clinical Program must perform vendor qualification of the IND or BLA holder. It is the FDA that monitors regulatory compliance, and the Clinical Program only needs to perform vendor qualification. Programs must verify the IND or BLA holder meets its needs in regards to many areas of cellular therapy, including labeling processes (label content applied by whom and how), level of service (turnaround times, customer inquiries), and other metrics defined by the program. Documentation of this qualification must be provided to the FACT inspection team.
- It is acceptable to delegate this activity to the Processing Facility so long as there is robust communication between the program and facility, which should be obvious in documentation.
Define Responsibilities
- The level of participation of the clinical service in manufacturing an immune effector cell product varies. Regardless of where the product is collected or manufactured, responsibilities must be clearly defined.
- If a Clinical Program is responsible for collecting cells or preparing the IEC product for administration, or if independently FACT-accredited cell collection and processing facilities contract with a manufacturer, FACT Standards for collection and processing apply to the steps performed.
- If products are received directly by the Clinical Program or intermediary facility (e.g., blood bank, pharmacy) from a third-party manufacturer, the following responsibilities must be defined at a minimum: chain of custody, product storage, verification of product identity, and management of adverse events. Additional responsibilities will be included in the new edition of FACT Standards to be published in March 2018.
FACT Announces 2017-2020 Strategic Plan
FACT’s strategic plan anticipates and addresses opportunities and challenges for the next several years. The strategic plan also identifies several “Defining Objectives.” Although all the goals in a strategic plan are important and meant to be accomplished, several are designated as highest priority. Accomplishing these priority goals defines FACT’s success over the next period of time.
The three defining objectives and additional goals for the 2017-2020 period are:
Defining Objective #1: INSPECTIONS
The highest possible level of excellence and consistency in inspections of programs and facilities.
Defining Objective #2: IMMUNE EFFECTOR CELL THERAPY
Rapid mobilization of an accreditation service for immune effector cellular therapy programs.
Defining Objective #3: FINANCES
Sufficient financial resources to sustain operations and build reserves for the development of mission-directed products and services and for surviving an economic downturn.
Strategic Objective #4: REGENERATIVE MEDICINE
Continued promotion of the FACT Common Standards for Cellular Therapies, and readiness to introduce disease- or medical specialty-specific standards when appropriate.
Strategic Objective #5: CLINICAL OUTCOMES IMPROVEMENT
Cellular therapy programs that know how to prevent, investigate and correct deficiencies in clinical outcomes.
Strategic Objective #6: STANDARDS
Clear and user-friendly FACT standards and effective transition between editions of standards.
Strategic Objective #7: ACCREDITATION
Consistency in the awarding of FACT accreditation.
Strategic Objective #8: CORD BLOOD BANKING
Recognition of FACT as the premier accreditation for both public and private cord blood banks.
Strategic Objective #9: EDUCATION
Recognition that education is as important as standards and accreditation within FACT’s mission to promote quality in cellular therapy.
Strategic Objective #10: ORGANIZATIONAL EFFECTIVENESS
Organizational health is one of FACT’s greatest strengths.
The Role of Medical Records During On-Site Clinical Program Inspections
Last year, FACT and CIBMTR announced their collaborative data assessment program, designed to reduce duplicative efforts, enhance quality improvement efforts, and provide support to accredited Clinical Programs. Not only has this program intensified support and improvement of Clinical Programs’ data management and reporting processes, it saves time for programs audited by CIBMTR by reducing the need to make Transplant Essential Data (TED) forms and source documentation available to FACT inspectors during the on-site inspection.
Despite the reduction in records to produce for the data audit, there is still a critical need for access to medical records during on-site inspections. Compliance with many standards can be verified through medical records including:
- Donor and recipient informed consent;
- Donor eligibility evaluation and determination;
- Compliance with established policies, procedures, and guidelines;
- Verification of preparative regimens and recipient identity against protocols;
- Detection, evaluation, reporting, correction, and prevention of adverse events and other occurrences; and
- Verification of corrective action plan implementation.
Pre-selected and organized medical records facilitate inspector review. Pre-select records that represent a variety of situations applicable to your program, including:
- Allogeneic, autologous, and haploidentical transplants;
- Transplants using cells derived from peripheral blood, bone marrow, and cord blood;
- Cellular therapy using novel products such as immune effector cells (IECs);
- Adult and pediatric patients; and
- Adverse events, positive microbial cultures, and ineligible donors. (Yes! Showing inspectors medical records that represent less than ideal, but inevitable, circumstances will improve the results of your inspection by allowing inspectors to verify compliance with all standards.)
(A note about electronic medical records (EMR): Because it takes time to navigate electronic systems, it will also take time for the inspector to become familiar with your EMR. Create printed shadow charts and/or plan to navigate the system for your inspector. It is a good idea to communicate with your inspector in advance regarding his/her preferences.)
With the time saved by eliminating the need to produce accessible copies of TED forms, spend time selecting medical records from a variety of situations, evaluate your processes and make improvements where necessary. Use this opportunity to show your inspector how you continuously improve your program. That is, after all, the real purpose of FACT accreditation.
Inspection of Fixed or Non-Fixed Cord Blood Collection Sites? That is the Question for FACT.
Cord blood banks accept the noble challenge of collecting what many still unfortunately consider medical waste – placental and umbilical cord blood – and transforming it into a lifesaving therapy. In many cases, this is accomplished by establishing formal relationships with specific hospitals and other birthing units, with a written agreement between the collection site and the bank for the collection of cord blood units. The agreement describes the interaction between the collection site and the bank for all aspects of the collection process including, at a minimum, personnel training, record keeping, collection, storage, and transportation or shipping of a cord blood unit.
There are also non-fixed collection sites, where the collection of cord blood is initiated by the infant donor’s mother or family. For these sites, banks must document that a health care professional has agreed to perform the collection in accordance with the cord blood bank’s collection procedures and must provide training that covers each aspect of the collection process. Cord blood collection at these sites are typically infrequent.
The NetCord-FACT International Standards for Cord Blood Collection, Banking, and Release for Administration make very few distinctions between fixed and non-fixed collection sites, because both types have a direct impact on the quality of the cord blood unit ultimately given to a patient. Therefore, because they perform a critical step of the cord blood banking process, facilities that collect cord blood units for an applicant cord blood bank are inspected during the accreditation process.
There are several models used by cord blood banks to collect placental and umbilical cord blood, and FACT and WMDA-NetCord acknowledge the need for banks to institute models that work best for them. Banks submit information about all collection sites to FACT; with that information, FACT determines what collection sites will be inspected as part of the accreditation process. Collection sites are selected depending on a number of variables to allow verification of compliance of all processes used by the bank. Examples of variables include:
- Distance from the bank,
- Mode of transport from the collection site to the bank (e.g., private courier, donor family, commercial shipper),
- Travel time between the collection site and bank,
- Temporary storage location between the collection site and bank,
- Average number of units collected per year,
- Method of collection (in utero, ex utero, or both),
- Type of unit (e.g., unrelated allogeneic, directed allogeneic), and
- Collecting professional (e.g., bank employee, obstetrician, collection site employee).
Sometimes, cord blood banks consider a relationship with a collection site to be non-fixed, but FACT still must inspect those sites because of their responsibilities. For example, collection sites that collect a large number of cord blood units a year, store collection kits, obtain informed consent, or perform other responsibilities may be inspected. Inspectors have identified areas for improvement at such collection sites, and we believe that the processes banks implement to address these issues will result in higher quality units. Many of the deficiencies are easily resolved by the bank, and place little burden on the collection sites themselves; sometimes they make the process better for the sites. For example, a high microbial contamination rate may be attributed to the collection process. The bank can decrease the contamination rate by providing clearer Standard Operating Procedures (SOPs) and training regarding preparation of the needle site and handling of equipment.
Michele Sugrue Outlines Her Recipe for Successfully Performing FACT Inspections
In 1997, the first book in the Harry Potter series was published in the United Kingdom. It was at that time, shortly after preparing for our program’s first “FAHCT” inspection, that I considered serving as an inspector. I felt that being able to visit other programs and observe operations firsthand would not only better expose me to the cellular therapy community and provide an educational experience, but also allow me to contribute to process improvement initiatives at the BMT program at UF Health. My first assignment was in 1998. While that seems like a lifetime ago, I continue to appreciate the opportunity to represent FACT as much today as I did back in the “20th century”. Since then, my goal is to perform at least two inspections each year, as either a Processing or Apheresis Collection Facility Inspector. Being qualified to perform inspections in both areas provides me an enhanced perspective of the cellular therapy product life cycle – collection, processing, storage, and administration. In the following paragraphs, I share some insights, approaches and “tricks of the trade” that I have learned along the way.
“Before anything else, preparation is the key to success.” Alexander Graham Bell
The most important preparation tip that I share with inspector trainees is to start the “desk” inspection early in order to allow ample time for thorough review. By planning sufficient time for review, well prior to the date of inspection, an inspector can request further information and clarifications. This ultimately allows for a more efficient inspection. I developed a personal SOP for inspection preparation titled, Preparing to Perform a FACT Inspection, which has undergone many revisions, been validated, and approved by Quality Management and continues to serve as the basis for my approach to inspections.
First, I confirm scheduling and travel arrangements with FACT office staff and the inspection team leader (I provide my cell phone number in case of emergencies). My next step is to review the application in order to understand the services provided, volume of activities, and organizational structure of the applicant program. I print the assigned inspector checklist, which contains applicant responses, and begin a comprehensive review of all documents provided in the application. Often several sections of the checklist can be completed by document review, such as label content requirements and key staff credentialing, well before departing for the applicant site. As I proceed through the checklist and review the QM Plan, SOPs and other documents; stickers with notations are placed next to Standards requiring further clarification or observation on site. In addition, I develop a written list of questions to have in hand upon arrival on the day of inspection. Preparation is not complete until the entire checklist and all documents have been reviewed. Yes indeed, I am “old-school,” and assemble a three-ring binder containing printed materials to have on hand during the inspection. It resembles a mini version of the original four-inch binders that were sent to inspectors before the accreditation portal was launched. My binder is complete with section dividers, is only one or two inches, and contains only area-specific printed materials. Once at the inspection site, I again work through the checklist and systematically remove the stickers and cross out items on my list. Ultimately, at the end of the day, what remains is a new list of potential citations and/or variances along with commendable practices.
“The best-laid plans of mice and men / Go oft awry.” Robert Burns
As inspectors, we diligently work to prepare for an efficient and well-structured inspection day. Occasionally, schedules fall apart. As such, we must exhibit flexibility and maintain composure and professionalism. Developing a detailed agenda with the inspection team and site coordinator can often avoid poor time management, yet unforeseen factors can impact the best of intentions. Amazingly, more often than not, I have arrived at a facility where no apheresis collections, product processing, or administration procedures have been scheduled for observation. That is when I quickly switch to “mock” procedure mode and work to allow sufficient time to perform a thorough observation. Being prepared prior to arrival on site with the skillset to examine both actual and “mock’” procedures puts the facility site at ease and allows the inspector to perform a complete review.
“Without continual growth and progress, such words as improvement, achievement, and success have no meaning.” Benjamin Franklin
After hours of preparation and a long day, inspectors will conduct an exit interview with the applicant program staff and institution leadership. I have come to approach these meetings in such a manner to avoid the unexpected and to offer positive feedback. I always make it a point to have discussed all significant potential citations, variances, and concerns with area managers and directors, if available, prior to the exit session. My standard exit session script begins by thanking the staff (by name) for their patience and hard work, no matter how well or poorly the day unfolded. I then reiterate that I have inspected the facility with the “X” Edition FACT-JACIE Standards and that the FACT Accreditation Coordinator will present my report to the FACT Accreditation Committee for review. I share my observations and potential citations and variances to the group with reference to specific examples. I consider it equally important to also describe commendable practices such as process improvement efforts, exemplary SOPs and worksheets, or praiseworthy practices or achievements. As inspectors, we cannot diminish the importance of the exit session, as it can often be what is most remembered of the inspection day’s activities by those in attendance.
It has been an honor and privilege for me to serve as a FACT Inspector. While it requires time and effort outside of my office and personal life, I am convinced that both my home BMT program and I greatly benefit from the experience. I encourage those interested to join the FACT inspectorate.
Congratulations to our New Inspectors!
The following individuals completed their first active inspection in the time period from January 2017 through September 2017. Congratulations and thank you for volunteering your time and expertise to advance cellular therapy! Organizations with personnel who also serve as FACT inspectors typically perform better during on-site inspections than their counterparts without an inspector. If you are interested in serving as an inspector, submit an online application!
Ibrahim Ahmed, MD
Cellular Therapy Clinical Program and Marrow Collection
The Children’s Mercy Hospital Blood and Marrow Transplant Program
Monzr Al Malki, MD
Cellular Therapy Clinical Program and Marrow Collection
City of Hope Hematopoietic Cell Transplantation Program
Nicole Aqui, MD
Cellular Therapy Apheresis Collection
Blood & Marrow Collection and Processing Program of the University of Pennsylvania Medical Center
Sherman Bakabak, BSMT(ASCP)
Cellular Therapy Processing: Minimal Manipulation of HPC
UCSF Benioff Children’s Hospital Pediatric Cellular Therapy Laboratory
Gloria Barrueco, BS, AMT
Cellular Therapy Processing: Minimal Manipulation of HPC
Blood and Marrow Transplant Center at Florida Hospital
Wendy Beron, MSN, RN, OCN
Cellular Therapy Apheresis Collection
NYU Langone Health Hematopoietic Progenitor Cell Transplant Program
Charlene Briedenbaugh, BS, HP, MLT(ASCP)
Cellular Therapy Apheresis Collection
Allegheny Health Network, Cancer Institute, West Penn Hospital
Yeong Choi, PhD
Cellular Therapy Processing: Minimal Manipulation of HPC
cGMP: Therapeutic Cell Production Facility
Omotayo Fasan, MBSS, MRCP
Cellular Therapy Apheresis Collection
The Center for Bone Marrow Transplantation at Geisinger Medical Center
Barbara Gagliardi, D.Sc
Cord Blood Banking
Milano Cord Blood Bank
Gerhard Hildebrandt, MD
Cellular Therapy Clinical Program and Marrow Collection
University of Kentucky Blood and Marrow Transplant Program
Jogesh Jethava, MD, FACP, MRCP (UK), FRCPath (UK)
Cellular Therapy Clinical Program and Marrow Collection
The Blood & Marrow Transplantation Program of the Holden Comprehensive Cancer Center at the University of Iowa
Sarita Joshi, MBBS, MD
Cellular Therapy Clinical Program and Marrow Collection
Cleveland clinic foundation, Department of Blood Banking and Transfusion Medicine
Deepika KC, MS, BS(ASCP)
Cellular Therapy Processing: Minimal Manipulation of HPC
Mayo Clinic Arizona
Sajad Khazal, MD
Cellular Therapy Clinical Program and Marrow Collection
The University of Texas MD Anderson Cancer Center Stem Cell Transplantation and Cellular Therapy Program
Wanda Koetz, RN, HP(ASCP)
Cellular Therapy Apheresis Collection
Memorial Blood Centers
Kathryn Suet Wa Leung, MD
Cellular Therapy Clinical Program and Marrow Collection
Children’s Healthcare of Atlanta Blood and Marrow Transplantation Program
Elina Linetsky, PhD
Cellular Therapy Processing: Minimal Manipulation of HPC
cGMP Cell Processing Facility Diabetes Research Institute University of Miami Miller School of Medicine
Parinda Mehta, MD
Cellular Therapy Clinical Program HPC
Cincinnati Children’s Hospital Medical Center, Cancer and Blood Diseases Institute, Bone Marrow Transplantation and Immune Deficiency Program
Andrea Meyer
Cord Blood Processing
José Carreras Cord Blood Bank Düsseldorf
Huy Pham, MD, MPH
Cellular Therapy Apheresis Collection
The University of Alabama Adult and Pediatric Bone Marrow Transplantation and Cell Therapy Program
Sai Ravi Pingali, MD
Cellular Therapy Clinical Program and Marrow Collection
Baylor College of Medicine, Stem Cell Transplant Program, Texas Children’s Hospital and Houston Methodist Hospital
Opal Preston, RN, BSN, MT (HEW), QIA
Cellular Therapy Apheresis Collection
University of Virginia Health System
Aravind Ramakrishnan, MD
Cellular Therapy Clinical Program and Marrow Collection
Texas Transplant Institute at Methodist Hospital, Methodist Children’s Hospital in San Antonio and South Austin Medical Center in Austin
Laleh Ramezani, BS, MLT
Cellular Therapy Processing: Minimal Manipulation of HPC
USC Blood and Marrow Transplant Program
David Shyr, MD
Cellular Therapy Clinical Program and Marrow Collection
The University of Utah Blood and Marrow Transplant Program
Roni Tamari, MD
Cellular Therapy Clinical Program and Marrow Collection
Memorial Sloan-Kettering Cancer Center – Blood and Marrow Transplant Program
Priti Tewari, MD
Cellular Therapy Clinical Program and Marrow Collection
Baylor College of Medicine, Stem Cell Transplant Program, Texas Children’s Hospital and Houston Methodist Hospital
Ravi Vij, MD, MBA
Cellular Therapy Clinical Program and Marrow Collection
Stem Cell Transplant Program at Barnes-Jewish Hospital and St. Louis Children’s Hospital at Washington University School of Medicine
