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Setting up Audit

Setting up Audit. ‘The Liverpool Experience’. Alan Clark Quality Manager Merseyside & Cheshire Regional Genetics Laboratory Liverpool Women’s Hospital Liverpool. Introduction. Audit.

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Setting up Audit

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  1. Setting up Audit ‘The Liverpool Experience’ Alan Clark Quality ManagerMerseyside & Cheshire Regional Genetics LaboratoryLiverpool Women’s HospitalLiverpool

  2. Introduction Audit ‘Systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which the audit criteria are fulfilled.’ D. Burnett, ‘Practical Guide to Accreditation in Laboratory Medicine’ ACB Venture Publications, 2002 ISBN 0-902429-39-6 After ISO 9000:2002- Quality Management Systems

  3. Starting Point • Standards checklist • compliance & evidence • Documentation checklist • existence • status

  4. Internal Audit Tools Sporadic • Complaints • Incidents • Suggestions Scheduled • Internal Quality Control • Activity data • Inspections (e.g. H&S) • Compliance with Standards and S.O.P.s • User satisfaction surveys

  5. Activity data • Spreadsheets • monthly data • conditional formatting (targets) • nett change to residual workload • rolling projection

  6. Compliance with SOPs & CPA Standards • Vertical Audit • Horizontal Audit • Examination (Witness) audit

  7. Organization of scheduled audit • Timetable • Personnel involved

  8. Timetable

  9. Who does Audit? • Cytogenetics • Sections audited by personnel from another section • QM oversees and documents & monitors actions • Molecular • QM performs audits • QM / HOD oversees • QM documents & monitors actions

  10. User Satisfaction Survey • HOD/ HOS and QM design questionnaire • QM mail merges and issues • HOD receives • QM analyses and reports • HOD/HOS and QM agree action plan • QM monitors

  11. Without Whom…. • D. Burnett • CPA (UK) Ltd. • Roger Mountford (LWH) • Peter Howard (LWH) • Angela Douglas (LWH) • Simon Patton (SMH) • Helen Clarke (Christie) • Susan Clark (Christie)

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