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.



Competency Area

Healthcare Services


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)