Setting up audit
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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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Setting up audit

Setting up Audit

‘The Liverpool Experience’

Alan Clark

Quality ManagerMerseyside & Cheshire Regional Genetics LaboratoryLiverpool Women’s HospitalLiverpool


Introduction

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


Starting point

Starting Point

  • Standards checklist

    • compliance & evidence

  • Documentation checklist

    • existence

    • status


Internal audit tools

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


Activity data

Activity data

  • Spreadsheets

    • monthly data

    • conditional formatting (targets)

    • nett change to residual workload

    • rolling projection


Compliance with sops cpa standards

Compliance with SOPs & CPA Standards

  • Vertical Audit

  • Horizontal Audit

  • Examination (Witness) audit


Organization of scheduled audit

Organization of scheduled audit

  • Timetable

  • Personnel involved


Timetable

Timetable


Who does audit

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


User satisfaction survey

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


Without whom

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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