Healthcare and clinics

PRACTICAL GUIDANCE

The starting point

Build assurance around the patient journey and the information that supports it. A management-system audit can examine governance and operational controls, while clinical judgement and regulatory oversight need their own competent assessment.

Priorities to examine

• Inconsistent booking, referral, reporting or follow-up processes create avoidable uncertainty.
• Sensitive information moves between clinicians, laboratories, technology providers and patients.
• Growth, new services or new premises change the governance and control needs.
• Leadership needs a clear view of complaints, incidents, staff concerns and the effectiveness of improvement actions.

Standards to investigate

Evidence to consider

• A service map covering referrals, appointments, treatment support, reporting and follow-up.
• Role, competence and authorisation records relevant to the agreed audit scope.
• Minimised or redacted evidence of complaints, incidents and learning actions.
• Information-access arrangements, supplier contracts and privacy risk decisions.
• Equipment maintenance, purchasing and outsourced-service oversight records where relevant.
• Governance meeting outputs that connect performance information to accountable decisions.

Questions for your scope

• Which services, professions, locations and outsourced activities are included?
• Which regulatory, contractual and professional requirements apply to those activities?
• Can the audit use anonymised or redacted examples instead of identifiable patient records?
• How are urgent issues distinguished from routine improvement actions?
• What specialist clinical or regulatory assessment is needed beyond the management-system review?

Related guidance and practical next steps