Supporting and Preparing Healthcare Organizations for Evaluations and External Audits
- From Standards and Compliance Documentation to the Systematic Embedding of Quality
Key Information
Estimated duration: 8 instructional hours (2 days)
Target audience: Administrative and scientific staff of healthcare organizations, quality and patient safety officers, self-assessment coordinators, members of clinical governance committees, department heads, and risk management and service improvement officers
Format: Online
Programme Description
This section helps healthcare organizations prepare effectively for mapping assessments and external audits by understanding what is being reviewed, what documentation is required, and how to demonstrate that the relevant requirements are being implemented in practice. Building on the structure and logic of the Common Assessment Framework for Health (CAF-H), participants will become familiar with the connections between pillars, dimensions, criteria, sub-themes, and indicators.
The training focuses on preparing for self-assessment, gathering and organizing evidence, conducting an evidence-based assessment of compliance, and collaborating effectively with the external evaluation team. At the same time, it highlights how the findings can be used to identify risks and priorities, develop corrective actions, and improve day-to-day operations.
The goal is not simply to gather documents in preparation for an audit, but to develop a consistent, evidence-based, and participatory approach to quality and safety: from individual criteria to improving the organization’s operations and fostering systemic learning.
Training Modules
- Healthcare Assessment: Purpose, Principles and Approaches
- Self-assessment and external assessment: roles, stages and complementarity.
- From the requirements of a standard to the assessment of their implementation and effectiveness.
- Structure of the Common Assessment Framework for Healthcare (CAF-H): pillars, dimensions, criteria, sub-criteria and indicators.
- Enabler criteria and results criteria; distinguishing between the existence of a procedure and its actual implementation in practice.
- Criteria Critical to Quality (CTQ) and Important to Quality (ITQ) criteria.
- Preparing the Healthcare Provider for Assessment
- Establishment of a self-assessment team, designation of responsible persons and points of contact.
- Understanding the scope of application and the requirements relevant to the type of healthcare provider.
- Planning the self-assessment process and coordinating the departments involved.
- Initial identification of gaps, outstanding issues and areas of increased risk.
- Documentation and Evidence of Compliance
- What constitutes appropriate evidence for each criterion and indicator.
- Policies, procedures, protocols, minutes, implementation records, data and results.
- Currency, completeness, traceability and consistency of evidence.
- Triangulation of evidence from documents, data, interviews, observation and feedback.
- Linking evidence to the corresponding criterion and avoiding fragmented or excessive document collection.
- Organisation of the evidence file and development of a criterion–evidence–responsible person mapping matrix.
- Self-Assessment, Evidence-Based Scoring and Maturity
- Interpretation of the criteria and establishing a common understanding of the assessment scale.
- Scoring based on implementation, monitoring and improvement.
- Reconciling different perspectives and reaching a consensus-based, evidence-supported assessment.
- PDCA/PDCAI approach: planning, implementation, checking and improvement or institutionalisation of improvement.
- Identifying the gap between formal compliance and the consistent integration of requirements into day-to-day operations.
- Application Across the Five Pillars of the CAF-H
1. Organisation, Leadership – Organisational Management, Clinical Governance and Sustainability
- Vision, mission, objectives, organisational structure, roles, responsibilities and accountability.
Strategic and operational planning, monitoring of decisions and project management.
Regulatory framework, standardisation of operations and implementation of policies.
Clinical governance, functioning of committees and linking managerial oversight with quality and safety.
Staffing, workforce development, material resources and infrastructure.
Sustainability objectives and monitoring.
- Vision, mission, objectives, organisational structure, roles, responsibilities and accountability.
2. Quality and Safety Policies – Person-Centred Care
- Quality, safety and continuous improvement policies.
- Rights, dignity, equitable access and participation of patients or service users.
- Communication, information provision, informed consent and support for participation in care.
- Management of complaints and utilisation of patient or service-user experience.
- Patient-Reported Experience Measures (PREMs) and, where applicable, Patient-Reported Outcome Measures (PROMs).
3. Risk Management – Safety of Service Users and Healthcare Professionals
- Identification and assessment of clinical, operational and occupational risks.
- Incident reporting systems, recording, classification and feedback.
- Incident investigation, root cause analysis and planning of corrective actions.
- Prevention and management of risks associated, among others, with medicines, infections, equipment and critical clinical processes.
- Occupational health and safety, emergency preparedness and emergency management.
4. Core Operational, Clinical (Diagnostic and Therapeutic) and Support Processes
- Standardisation and monitoring of key care pathways: admission or attendance, diagnosis, treatment, follow-up, referral, transfer and discharge.
- Implementation of clinical guidelines, protocols and care plans.
Continuity of care and coordination between departments and healthcare professionals.
Support functions, such as procurement, maintenance, laboratories, information systems and records management.
Tailoring the assessment to the functions of each healthcare provider, including hospital care, Primary Health Care (PHC), mental health, public health and rehabilitation.
5. Continuous Monitoring and Improvement
- Data governance: data quality, completeness, sources and traceability.
- Definition of indicators with clear specifications, numerator, denominator, data source and measurement frequency.
Monitoring of KPIs, trends and targets; reporting and performance dashboards.
Internal audits, management reviews and benchmarking across comparable services.
Improvement plans, corrective actions, designated responsible persons, timelines and verification of effectiveness.
Monitoring of recurring findings and integration of lessons learned into established practices.
- External Assessment in Practice
- Preparation of the assessment visit schedule, documentation and access to services.
- Management of evidence requests, interviews and on-site observations.
- Participation of managers and healthcare professionals, ensuring a clear and consistent presentation of the provider’s practices.
- Professional communication with the assessment team and clarification of findings.
- Verification of the factual accuracy of the assessment report and provision of an evidence-based response.
- From Findings to an Improvement Plan
- Analysis and prioritisation of findings based on their significance, risk and impact on care.
Distinguishing between isolated deviations and systemic problems.
Development of a corrective and improvement action plan, with designated responsible persons and milestones.
Monitoring progress and evaluating the effectiveness of implemented actions.
Transferring lessons learned across services, teams and subsequent assessment cycles.
- Practical Exercise
- Review of an indicative criterion and its supporting evidence.
- Development of a concise criterion–evidence mapping table.
Formulation of an assessment finding and development of a basic corrective action plan.
Learning Outcomes
Upon completion of this module, participants will be able to organize the organization’s preparation, match the criteria with appropriate supporting documentation, contribute to a consistent self-assessment, and translate the findings into actionable improvement measures.
Expression of Interest
Complete the expression of interest form to receive information about upcoming programme dates and future training opportunities.