{"id":10680,"date":"2024-12-11T14:26:16","date_gmt":"2024-12-11T13:26:16","guid":{"rendered":"https:\/\/extali.eu\/docs\/3-krankenhausleitung\/3-7-qm-koordination\/3-7-10-interne-audits\/"},"modified":"2025-08-07T11:44:07","modified_gmt":"2025-08-07T09:44:07","slug":"3-7-10-internal-audits","status":"publish","type":"docs","link":"https:\/\/gutehospitalpraxis.de\/en\/handbuch\/3-krankenhausleitung\/3-7-qm-koordination\/3-7-10-interne-audits\/","title":{"rendered":"3.7.10 Internal audits"},"content":{"rendered":"<h2 class=\"wp-block-heading\">1 Aim and purpose<\/h2>\n\n\n\n<p>For regular audits, the requirements from the \"regulated area\" (laws, regulations, etc.) and from the hospital's quality objectives are transferred to checklists. The same procedure can also be used to check requirements for other hospital services. Compliance with the requirements can also be checked by spot checks or by monitoring indicators.<\/p>\n\n\n\n<p>Audit planning, reporting and checklists are set out in an audit manual.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">2 <a>Application<\/a><\/h2>\n\n\n\n<p>According to the specifications of the audit programme in the planned departments and areas.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">2.1 General information<\/h3>\n\n\n\n<p>Audits can be carried out routinely or on special occasions, such as significant changes in management, in the quality management system, in the service, in the service delivery process or in the follow-up of corrective actions.<\/p>\n\n\n\n<p>With internal audits in particular, care must be taken to ensure that they do not lead to responsibility for achieving the quality objectives being shifted from the operating personnel to the quality assurance unit.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">2.2 Audit objectives<\/h3>\n\n\n\n<p>An audit can have the following objectives:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Determining whether or not the elements of the QM system fulfil the specified requirements<\/li>\n\n\n\n<li>Determining the effectiveness of the QM system with regard to the fulfilment of the defined quality objectives<\/li>\n\n\n\n<li>Fulfilment of requirements from regulations<\/li>\n\n\n\n<li>to show the audited organisation ways to improve the QM system.<\/li>\n\n\n\n<li>The standard gives the following examples:<\/li>\n\n\n\n<li>Improvement of a management system and its performance<\/li>\n\n\n\n<li>External requirements, e.g. certification according to a management system standard<\/li>\n\n\n\n<li>Verification of contractual requirements<\/li>\n\n\n\n<li>Confidence in the ability of a supplier<\/li>\n\n\n\n<li>Evaluation of the effectiveness of the management system<\/li>\n\n\n\n<li>Assessment of the compatibility and alignment of these objectives with the policy of the management system and the overall corporate objectives<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">1.3 Reasons for an audit<\/h3>\n\n\n\n<p>An audit can be carried out in order to<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>to obtain an initial assessment of a supplier before concluding a contract;<\/li>\n\n\n\n<li>To prove that a supplier's QM system fulfils and implements the specified requirements on an ongoing basis<\/li>\n\n\n\n<li>evaluate its own QM system;<\/li>\n\n\n\n<li>To prove that the company's own QM system fulfils the specified requirements on an ongoing basis and has been implemented.<\/li>\n<\/ul>\n\n\n\n<p>The DIN EN ISO 19011 standard lists further aspects that should be considered when defining an audit programme:<\/p>\n\n\n\n<p>a) Management priorities;<\/p>\n\n\n\n<p>b) commercial and other business intentions;<\/p>\n\n\n\n<p>c) Characteristics of processes. products and projects as well as changes to these;<\/p>\n\n\n\n<p>d) Management system requirements;<\/p>\n\n\n\n<p>e) legal and contractual requirements and other requirements to which the organisation is committed;<\/p>\n\n\n\n<p>f) Requirement of supplier assessment:<\/p>\n\n\n\n<p>g) Requirements and expectations of interested parties, including customers;<\/p>\n\n\n\n<p>h) Performance level of the organisation to be audited, as reflected in the occurrence of errors, incidents or customer complaints;<\/p>\n\n\n\n<p>i) Risks for the organisation to be audited;<\/p>\n\n\n\n<p>j) Results from previous audits;<\/p>\n\n\n\n<p>k) Maturity of the management system.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Description of the<\/h2>\n\n\n\n<p><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2025\/06\/3.7.10_00_QM_Internes-Audit_10.docx\">Text of the VA 3.7.10 Internal audits<\/a><\/p>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"anlagen\">9 Systems<\/h2>\n\n\n\n<p><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2025\/06\/3.7.10_01_QM_Kommunikationstechnik.docx\">Appendix 1: Communication techniques<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2025\/06\/3.7.10_02_QM_Anforderungen-an-Auditor.docx\">Appendix 2: Requirements for the competence of the auditor<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2025\/06\/3.7.10_03_QM_auditor_qualifikationsnachweis.docx\">Appendix 3: Proof of competence of the auditor<\/a><\/p>\n\n\n\n<p><a href=\"https:\/\/gutehospitalpraxis.de\/wp-content\/uploads\/2025\/06\/3.7.10_04_QM_Audit_Ablauf_word.docx\">Appendix 4: Audit procedure (flow chart)<\/a><\/p>","protected":false},"excerpt":{"rendered":"<p>1 Ziel und Zweck F\u00fcr regelm\u00e4\u00dfige Audits werden die Anforderungen aus dem &#8222;geregelten Bereich&#8220; (Gesetze, Verordnungen usw.) und aus den Qualit\u00e4tszielen des Krankenhauses in Checklisten \u00fcbertragen. Nach demselben Verfahren k\u00f6nnen auch Anforderungen an andere Leistungen des Krankenhauses gepr\u00fcft werden. Die Einhaltung der Forderungen kann auch durch Stichprobenpr\u00fcfungen oder durch Beobachtung von Indikatoren gepr\u00fcft werden. In [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":10648,"menu_order":159,"comment_status":"open","ping_status":"closed","template":"","doc_tag":[],"doc_badge":[],"class_list":["post-10680","docs","type-docs","status-publish","hentry","no-post-thumbnail"],"acf":[],"author_avatar":"https:\/\/secure.gravatar.com\/avatar\/c6b2616140d9fcd6a1c5d6d2ebbf43422308c9322c032ef03f88ec3235855dcf?s=96&d=mm&r=g","author_name":"admin","_links":{"self":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10680","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs"}],"about":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/types\/docs"}],"author":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/comments?post=10680"}],"version-history":[{"count":6,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10680\/revisions"}],"predecessor-version":[{"id":15790,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10680\/revisions\/15790"}],"up":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10648"}],"wp:attachment":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/media?parent=10680"}],"wp:term":[{"taxonomy":"doc_tag","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/doc_tag?post=10680"},{"taxonomy":"doc_badge","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/doc_badge?post=10680"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}