Jersey City Medical Center Barnabas Health

• Conducted on

  Date

• Auditor Name

• Document No.

• Audit Location / Department

• Audit Scope / Focus

• Related documentation, regulatory, or accreditation requirements?

Define who has responsibility, authority and/or ownership of this process? ISO9001:2008 5.5.1. (Capture roles or each process owner.)

• Role of Director / Manager?

• Role of Staff?

• Role of Outsourced (contracted service / staff)?

• Compliant

  OFI

  Non-Compliant

• Audit Notes

• Compliant (no follow-up required)

Define -- Do you have a Documented Procedure? ISO9001:2008 4.2.1 (Consider policies, procedures, checklists, tools, forms to be completed.) How do you know that it is the latest version? ISO9001:2008 4.2.3

• Documents Reviewed : Review / Revision Date

• Approved

  Off

  On

• Changes / Current Revision Status Indentified

  Off

  On

• Available at point of use?

  Off

  On

• Current Version

  Off

  On

• Compliant

  OFI

  Non-Compliant

• Audit Notes

• Compliant (no follow-up required)

What are the training requirements for this process? ISO9001:2008 6.2.2 (Consider training, educations, skills). Can you show me evidence of training or training records? ISO9001:2008 4.2.4

• Education, Training = Competency?

• Records of competency?

• Compliant

  OFI

  Non-Compliant

• Audit Notes

• Compliant (no follow-up required)

Define The Process

• Walk me through the process...

• Add media

  Media

• Add drawing

  Drawing

• Add media

  Media

• Compliant

  OFI

  Non-Compliant

• Audit Notes

• Compliant (no follow-up required)

Define the Objectives for this process? ISO9001:2008 5.4.1

• Are objectives related to the strategic plan? Determine whether objectives are measurable and relevant to the department or functional-area. Why was this process selected?

• Compliant

  OFI

  Non-Compliant

• Audit Notes

• Compliant (no follow-up required)

Measure & Monitor ISO9001:2008 8.2.3 / 8.2.4

• Show/explain to me how you measure the objectives? What activities occur to monitor this process?

• Compliant

  OFI

  Non-Compliant

• Audit Notes

• Compliant (no follow-up required)

Analysis ISO9001:2008 8.4

• What do you do with the data you have collected? How do staff know how their unit/department is performing? Evaluate Results for Levels, Trends, Comparisons and Integration (Segmentation)

• Compliant

  OFI

  Non-Compliant

• Audit Notes

• Compliant (no follow-up required)

Improve and Control ISO9001:2008 8.5.1 / 8.5.2 / 8.5.3

• Is there any opportunity for continual improvement, corrective action or preventive action? Please explain. What have you learned as a result of evaluating this process?

• Yes

  No

  N/A

• Audit Notes

• Compliant (no follow-up required)

ADLI

• Evaluate the PROCESS for ADLI <br>

  Approach

  Deployment

  Learning

  Inegration

LeTCI

• Evaluate the RESULTS of the process for LeTCI

  Levels

  Trends

  Comparisons

  Integration