[Clinic name]
Controlled document
[Address]
[Registration or licence number]
HIS inspection checklist
1Before HIS writes
- Check your certificate of registration matches what you offer, and that every variation was approved.
- Close every requirement and recommendation from registration, your last inspection and any complaint investigation.
- Keep your self-evaluation current, with three priorities and an action plan for each.
- Keep the records HIS lists inside the service, unless HIS has agreed otherwise in writing.
2Direction
- Aims, objectives and values that patients and staff can see.
- Key performance indicators that include patient safety, reviewed at governance meetings.
- Minutes of management and clinical governance meetings, with actions and owners.
- Practising privileges agreements that say who is accountable for what.
3Implementation and delivery
- Patient feedback gathered in one structured way, with what changed because of it.
- A complaints procedure on your website that names HIS and says patients can contact HIS at any time.
- A risk register reviewed by senior staff who did not write it.
- An annual duty of candour report, published.
4Results
- Five patient care records a reviewer could read cold, complete, signed and dated.
- Consent recorded for every treatment, with risks and aftercare.
- Staff files with two references, PVG membership, training and appraisal.
- Lessons learned from complaints and adverse events, and what changed.
5What an HIS inspector may ask
- Show me five patient care records. What to show, records completed, signed and dated, with consent, treatment and aftercare.
- How do patients consent, and where is it recorded? What to show, what the patient was told, when they agreed, and where it is written.
- How do you know what patients think of the service? What to show, feedback gathered in one place, with what changed because of it.
- How are complaints handled? What to show, a log, an investigation, and a reply within 20 working days.
- Walk me through your last adverse event. What to show, the sequence of events, the review, the notification and what changed.
- Are prices clear before a patient commits? What to show, the price and policy a patient sees before booking.
- Who can see patient records, and how would you know? What to show, roles, access controls and an access log.
- How do leaders know how the service is performing? What to show, key performance indicators, read at governance, with actions that close.
AAppendix, Inspection day pack
- A.1Certificate of registration and conditions, checked on ______
- A.2Open requirements and recommendations, with evidence for each ______
- A.3Self-evaluation, last submitted on ______
- A.4Five patient care records audited on ______ by ______
- A.5Staff files checked for references, PVG, registration and training on ______
- A.6Complaints log and duty of candour report, current to ______
- A.7Lead for Direction ______ Implementation and delivery ______ Results ______