Auditing, Evaluation and Service Design
Implement, evaluate and develop healthcare audit standards and compliance processes to objectively assess the effectiveness of processes (such as governance, accountability, control and risk management ) towards quality healthcare delivery and patient safety.
Type
Domain
Competency Area
Healthcare Services
Levels
Understands healthcare audit requirement and processes
Understands different ways of monitoring or auditing practice, sources of feedback, data sources etc. to facilitate audit and feedback mechanism (paper based forms, patient surveys, peer audits etc.)
Recognizes different levels of responsibility and involvement (individual health professionals, department, hospital, regional) during healthcare audit process
Understands regulatory frameworks used in accreditation or organizational assessments (such as NQAS, LAQSHYA- labor room quality standards, outbreak reporting, ) and lists compliance processes in accordance with department's strategy and regional and national requirements
Identifies gaps in practices and personnel capacity
Identifies good practices for sharing, learning and implementation across system
Identifies gaps in actual practices (current and past) in healthcare settings, compliance with/or deviation from statutory, regulatory and governance standards
Documents case reviews, individual risk incidents, departmental compliances etc. to assess public health services against established criteria for performance
Identifies education and training needs for workforce involved in internal audit and process evaluation
Conducts oversight
Proposes quality improvement interventions using clinical audit methodology and its effectiveness in improvement of risk management and control processes
Reviews risks associated with stretched provisions for timely communication with the senior leadership team
Determines internal as well as external monitoring protocols for the production, analysis and interpretation of data for comparison and compliance
Conducts appropriate training and education for audit personnel as per identified needs
Champions evidence-informed standards
Advances the use of global health audit frameworks and mechanisms (NHS Internal Audit Standards)
Promotes research into the gaps in evidence towards developing evidence-based compliance and practice standards
Encourages the development and maintenance of effective lines of communication to enable proactive reporting of compliance concerns with senior authorities
Motivates stakeholders and auditing partners to shift towards values-based compliance from rules-based compliance (HSE Code of Standards and Behaviors)