12.3 A risk based methodology is Applications for use of new equipment/procedures with Staff interview. IA+ED Onsite applied to the approval of new evidence that a risk assessment has been undertaken Document review procedures and equipment, within the ED/ UCC Monitoring of risk 13.1 ED/UCC risks that have been Risk register Document review Onsite IA occurs regularly identified as requiring action have assoIACTed action plans with strategies for risk reduction, timelines and responsibilities 13.2 Risk rating of identified ED/UCC Risk register shows progression of risk management Document review Onsite IA risks changing over time (mitigating) 13.3 ED/UCC Risk escalation is Evidence if risk escalation to appropriate position Document review IA Onsite consistent with the organisation’s risk management framework Controls put in 14.1 Testing of contols identified in risk Audit occurs against known high risks Document review IA+ED Onsite place to manage assesssment (procedures, clinical key risks are guidelines compliance) occurs monitored for periodically effectiveness Risk reporting and 15.1 The risk profile of the ED/UCC is Periodic risk profiling and reporting Document review IA Offsite communication is reported to relevant risk committee effective
12.3 A risk based methodology is applied to the approval of new procedures and equipment, within the ED/ UCC Applications for use of new equipment/procedures with evidence that a risk assessment has been undertaken Staff interview. Document review Onsite IA+ED Monitoring of risk occurs regularly 13.1 ED/UCC risks that have been identified as requiring action have assoIACTed action plans with strategies for risk reduction, timelines and responsibilities Risk register Document review Onsite IA 13.2 Risk rating of identified ED/UCC risks changing over time (mitigating) Risk register shows progression of risk management Document review Onsite IA 13.3 ED/UCC Risk escalation is consistent with the organisation’s risk management framework Evidence if risk escalation to appropriate position Document review Onsite IA Controls put in place to manage key risks are monitored for effectiveness 14.1 Testing of contols identified in risk assesssment (procedures, clinical guidelines compliance) occurs periodically Audit occurs against known high risks Document review Onsite IA+ED Risk reporting and communication is effective 15.1 The risk profile of the ED/UCC is reported to relevant risk committee Periodic risk profiling and reporting Document review Offsite IA
vmia_ecucc_internal_audit_tool_d17-63759.docx