Oklahoma Heart Hospital ISO Internal audit

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Department audited

• Date of audit

  Date

• Date audit closed

  Date

Departmental review

• Do staff know the departments scope of service?

  Yes

  No

  N/A

• Comments/answers

• Does the departments scope of service include Admission/Treatment/Discharge process?

  Yes

  No

  N/A

• Comments/answers

• Do staff know where to access policies and procedures?

  Yes

  No

  N/A

• Comments/answers

• Can staff verbalize how policies and procedures are maintained?

  Yes

  No

  N/A

• Comments/answers

• Do staff know how to verify it is the most current policy?

  Yes

  No

  N/A

• Comments/answers

• Can staff verbalize how to verify they have the most current version of a policy?

  Yes

  No

  N/A

• Comments/answers

• Is only the most current information displayed on the bulletin board?

  Yes

  No

  N/A

• Comments/answers

• Can staff verbalize how ,leadership communicates important information to them?

  Yes

  No

  N/A

• Comments/answers

• Can the staff verbalize our mission and vision?

  Yes

  No

  N/A

• Comments/answers

Human Resources

• Can staff verbalize how they were oriented to the hospital?

  Yes

  No

  N/A

• Comments/answers

• Can staff verbalize how their competency is assessed and maintained?

  Yes

  No

  N/A

• Comments/answers

• Have staff received periodic in-services or training regarding their job responsibilities?

  Yes

  No

  N/A

• What were some topics?

• Can staff verbalize who is responsible for the supervision of students when they provide patient care and who is responsible for the patient?

  Yes

  No

  N/A

• Comment/answer

• Do staff know what to do if they feel they cannot provide care to a patient due to religious or cultural values?

  Yes

  No

  N/A

• Comment/answer

Process review

• Process or procedure audited:

• Is there a documented policy and procedure for the process audited? Review the document

  Yes

  No

  N/A

• Comments/answers

• Can staff verbalize how to verify that it is the most current version?

  Yes

  No

  N/A

• Comments/answers

• Can staff verbalize if training is required for this process ?

  Yes

  No

  N/A

• Are training records/certificates available if training is required?

  Yes

  No

  N/A

• Can staff walk you through the process?

  Yes

  No

  N/A

• Comments/answers

• Can staff verbalize PI activities for their department ?

  Yes

  No

  N/A

• What are the activities and what has improved?

• Do you have the tools, equipment and resources to perform this process?

  Yes

  No

  N/A

• Comments/answers

• Are there any corrective, preventive or improvement opportunities we can help you with?

  yes

  no

• What can we help with?

Action

• Is a corrective or preventive action required

  yes

  no

• Which action is required?

  corrective

  preventive

• Cause of the nonconformity

• Organizational plan

• Person or position responsible for implementation of action plan

• Date actions implemented

  Date

• Results of actions taken

• Determine actions needed by

• Review of effectiveness