Controls put in place Testing of contols identified in risk Audit occurs against known high risks Document review Onsite IA+Clinical to manage key risks assesssment (procedures, clinical Expert are monitored for guidelines compliance) occurs effectiveness periodically Risk reporting and The risk profile of the Service/Unit Periodic risk profiling and reporting Document review IA Offsite communication is is reported to relevant risk effective committee Communication to staff occurs Staff interview, IA Onsite regarding key Service/Unit risks document review and emerging risks and management strategies (minutes, agendas, bulletins) There is clear ownership of risk Risk register demonstrates risk ownership Document review IA Onsite management through allocation of risk portfolios to Service/Unit staff All incidents and near Service/Unit incidents, adverse Review of incident register Incident database Onsite Clinical misses are reported, events and near misses are Review of audits from patient file review for coverage of review Expert appropriately recorded in the incident system all incidents documentated and managed Management are able to track the Incident reporting finding trends data over 3yr period Report review Clinical Onsite incident trends in the Service/Unit Expert and there is evidence of action taken
Controls put in place to manage key risks are monitored for effectiveness Testing of contols identified in risk assesssment (procedures, clinical guidelines compliance) occurs periodically Audit occurs against known high risks Document review Onsite IA+Clinical Expert Risk reporting and communication is effective The risk profile of the Service/Unit is reported to relevant risk committee Periodic risk profiling and reporting Document review Offsite IA Communication to staff occurs regarding key Service/Unit risks and emerging risks and management strategies (minutes, agendas, bulletins) Staff interview, document review Onsite IA There is clear ownership of risk management through allocation of risk portfolios to Service/Unit staff Risk register demonstrates risk ownership Document review Onsite IA All incidents and near misses are reported, appropriately documentated and managed Service/Unit incidents, adverse events and near misses are recorded in the incident system Review of incident register Review of audits from patient file review for coverage of all incidents Incident database review Onsite Clinical Expert Management are able to track the incident trends in the Service/Unit and there is evidence of action taken Incident reporting finding trends data over 3yr period Report review Onsite Clinical Expert
vmia-generic-internal-clinical-audit-tool-iact-d17-46220.docx