Getting Better All the Time

Doing This One Thing - Preparing an Inspection Checklist - is Invaluable

By James F. Gesualdi

To keep ahead, each one of us, no matter what our task, must search for new and better methods—for even that which we now do well must be done better tomorrow.
—James F. Bell

The way to get ahead is to start now.
—William Feather

The most effective way to do it is to do it.
—Toni Cade Bambara

Preparing an inspection checklist well in advance of an Animal Welfare Act (AWA) inspection improves animal well-being, empowers staff, promotes excellence, builds a strong compliance record, fosters goodwill, and upholds the public trust. It is one thing you can do to make the lives of animals better and make you and your organization look good, demonstrating that you are thoughtful, responsible, well-prepared professionals who are doing the right thing.

This and other Excellence Beyond Compliance® good practices work well in any enforcement climate because they help you and your organization demonstrate that you are proactively doing the right thing for the animals for the right reason.

The Inspection Checklist Idea Is Not New, but It Has Newfound Importance

The idea of the inspection checklist has been shared with clients and others for many years, and it was memorialized in the Excellence Beyond Compliance® book over a decade ago:

Developing an inspection checklist for the entrance briefing:

The constructive value of regulatory inspections is greatly enhanced when a compliance officer has a well-thought-out and organized checklist of items the zoological organization wants to be certain to cover. Therefore, the compliance officer, in consultation with the Animal Welfare Officer, should maintain an up-to-date running list of items to discuss with the inspector at the beginning of the next inspection, creating an inspection checklist to be used to present an entrance briefing to the inspector. Items to be noted on such a checklist and at the beginning of the inspection include:

Update on corrections to any prior noncompliant items, including making available any supporting materials for self-certified compliance reporting, as discussed in Chapter VI: After an Inspection, items 4, 6, and 7, and Chapter X: Agency Measures, items 3–5.
Overview of any noteworthy improvements or modifications in zoological organization activities, facilities, operations, staff and training since last inspection.
Questions or requests for guidance from the inspector with respect to any particular situations or potential plans.
Questions for the inspector regarding any changes or updates in agency guidance or practices relevant to the zoological organization.
Any other special situations (e.g., animals receiving critical care, pregnant or nursing females, new arrivals, deaths, staff changes).
Any areas or situations of particular interest or concern to the inspector (to be determined through discussion with inspector either prior to or at the time of the entrance briefing).

Reprinted with permission from James F. Gesualdi, Excellence Beyond Compliance: Enhancing Animal Welfare Through the Constructive Use of the Animal Welfare Act (2014).

Evolving Changes in AWA Administration and Enforcement

Unless one is attuned to many different factors and situations arising around the AWA and then connects the dots, it is not always easy to discern changes and patterns. Individual organizations are inspected periodically and may encounter challenges or difficulties, but these may fade from being top-of-mind concerns when pressing needs arise due to the unending responsibilities of caring for animals.

With thanks to Jen Charette, Jesse Daniels, and the rest of the team at TESSERE, I provided a brief presentation and interaction with zoological leaders in an ECHO Digital program in September. My opening remarks on “Addressing Animal Well-Being: Lessons from Animal Welfare Act Administrative and Enforcement Trends” provided a comprehensive overview of AWA-related trends within a constructive context. This is clearly an era of heightened enforcement, with more noncompliances being written up; increased enforcement activity regarding “critical” noncompliances, including those with serious adverse animal welfare impacts; and issuance of official warning letters. To understand things more fully, the inspection reports underlying official warning letters issued to accredited zoological organizations were examined. This review suggests that, in addition to some potential recalibrations on the agency’s part, there is room for zoological organizations to improve. (For more information on the presentation, please contact TESSERE at echo@tessere.com.)

You can take some actions to address noncompliances, the inspection report narrative, and enforcement activities like official warning letters. Following the issuance of an inspection report, one can make an inspection report appeal (9 C.F.R. § 2.13); see also Animal Care Tech Note: Inspection Report Appeals Process, here.

Appeals can be very helpful and positive for all concerned, especially when brought in the right spirit and proper way—a subject discussed and written about elsewhere. There are different rules for pre-licensing or relicensing inspections, in that only a third pre-licensing or relicensing inspection report can be appealed (9 C.F.R. § 2.3(c)).

If the appeal is not fully successful or if an enforcement action is limited to an official warning letter, there are things that can be done to demonstrate good faith action toward doing the right thing, such as improvement plans and follow-up reports and disclosures. (More involved enforcement actions for the most serious of situations are beyond the scope of this column.)

All of the above may prove beneficial in the end, but the process may strain staff time and other resources. Additionally, they are somewhat less effective than getting things right before and during the inspection and in the initial inspection report. The key to success in the inspection process is fully utilizing an inspection checklist as early as possible during the entrance briefing with the inspector, as well as during the conduct of the inspection itself and the exit briefing—and especially during review of the draft inspection report.

One Thing Everyone Can Do Now to Better Prepare for Inspections

Employing a good inspection checklist—and having backup documentation as appropriate—during the entrance briefing should do most of the work for you. It will also be a big help to the inspector. Putting in the effort to prepare for AWA inspections is a worthy investment of your time, and a way to further empower and develop staff and build a better working relationship with your inspector. Your checklist is a record of where you are and where your organization is heading. It is a well-thought-out game plan for a successful inspection that makes the most of your exchanges with your inspector—and fosters continuous improvement.

Based on the inspection report analysis from the ECHO Digital program, here are some additional points of emphasis to cover in your inspection preparation and documentation, including the inspection checklist:

Any situations which may have involved or resulted in death and/or adverse animal welfare impacts, whether in the past, possibly “critical,” or at the time of inspection, “direct.” These may be found to be critical noncompliances, and one can trigger an enforcement action in the form of an official warning letter at this time. For animals that have passed, mortality reviews (beyond necropsy and routine testing) are strongly recommended. With respect to any item of potential inspector concern, including unsuccessful introductions, veterinary care, and facilities-related matters, it is important to be able to explain and document incorporation/integration and adherence to AWA regulations (which may sometimes require conflicting things); available agency guidance (such as the Animal Welfare Inspection Guide, Tech Notes and Animal Care Aids, and regulatory history); professionally accepted standards and guidelines (for accreditation); Species Survival Plan, Taxon Advisory Group recommendations, and other professional practices; and relevant scientific literature. Your own practices and policies, the underlying basis for them, and your records can also prove invaluable in demonstrating proper approaches.
Pay attention to the timing element. Reading inspection reports always yields a lot more information than what appears on the written page. Dates provided and referenced tell a great deal about staff observations, empowerment, training, and relationships. Timing can also demonstrate prompt responsive action and that things like introductions were carefully managed.
Think in terms of bigger facility-wide improvements based on the additional self- examination inherent in inspection preparation. Some may be fearful that doing more is an admission that something may have gone wrong, however, it demonstrates that the organization’s greatest commitment is to do the right thing. A sample Excellence Beyond Compliance Inspection Checklist is available here.
Keep a few select passages from the Animal Welfare Inspection Guide with your inspection checklists and in your inspection binder or folder.
2.7: Exit interview
Please be certain to have a full exit briefing to review, and discuss any noncompliances and the wording of the inspection report. Question as appropriate, and request corrections in content and wording if justified. It is much easier to do so now than on appeal.

2.17.1: Inspection Report Review and Inspection Report Review Checklists
(at A-16 to A-17 in the Appendix of Forms and Worklists)
Review the same checklist the inspectors use to make sure you have addressed anything warranting further review and conversation. Note: be sure that any items fixed per or during inspection are noted as “corrected” at the time of inspection.

Be Ready

Agency inspectors are rightfully trained and prepared to inspect your facility. You and your team should be similarly trained and prepared.

In addition to their own backgrounds and experiences, including veterinary training for veterinary medical officers, inspectors are fully trained. Inspector and inspection training includes section-by-section review of the regulations in the agency’s “Blue Book,” which is just under an inch thick. They are also trained on inspections, inspection process, inspection findings and documentation, and writing inspection reports. Over the years, having read thousands of inspection reports, this training has resulted in more consistent and measured inspection reports, though there remain variations among inspections.

Keeping an up-to-date inspection checklist (and accompanying inspection binder or folder) is on-the-job training for you and your team. It can be a point of pride during and after an inspection. A good inspection checklist is always ready just when you need it most.

Inspection checklists require a commitment of time, attention, expertise, and other resources. This is a worthwhile investment for zoological organizations and zoological professionals prioritizing improving animal well-being, empowering staff, promoting excellence, building a strong compliance record, fostering goodwill, and upholding the public trust. Making it so is up to you!

The value of an idea lies in the using of it.
—Thomas Edison

There are opportunities even in the most difficult moments.
—Wangari Maathai