Milanesi Marco, Fiorito Rita, Caloccia Lara, Guglielmetti Chiara, Giganti Giulia, Andreasi Sara Elisa, Triarico Antonio
Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
BMJ Open Qual. 2025 Jan 28;14(1):e003012. doi: 10.1136/bmjoq-2024-003012.
The increasing emphasis on risk management and quality assessment in hospital management necessitates strict adherence to government and international standards. Those standards are particularly important, and certification requirements further underscore this need. The objective of this paper is to outline the application of the INTegrated Audit Model in a Comprehensive Cancer Center. This model represents a revised version of Tracer Methodology, for audit surveys, aimed at aligning audit activities with UNI EN ISO 9001:2015 and Joint Commission Standards for quality, patient safety and clinical risk management.Using the INTegrated Audit Model, a total of 7 tracers were conducted, and 31 units underwent auditing during the period spanning from 2022 to 2023. Each audit inquiry was documented, categorised and cross-referenced with International Organization for Standardization (ISO) and Joint Commission International (JCI) standards. Areas exhibiting the highest incidence of non-conformities and observations were systematically linked to relevant standards. Subsequently, a comprehensive analysis was conducted on the ensuing findings.The INTegrated Audit Model allowed for systematic data collection across clinical pathways, revealing prevalent issues and areas for improvement in patient care. By aligning identified topics with ISO and JCI standards, compliance with international guidelines was assessed, offering units insight into their current status and areas for enhancement.Overall, both auditees and auditors expressed satisfaction with the methodology and continuous training, highlighting its effectiveness in fostering collaboration, improving time management and promoting adherence to accreditation standards.The study highlights the effectiveness of the methodology in monitoring unit activities and adherence to clinical pathways and international standards applied to an oncological setting. Audits conducted with this approach provided a thorough assessment of critical areas impacting patient care and clinical governance, contributing to a comprehensive understanding of service delivery.
医院管理中对风险管理和质量评估的日益重视，使得必须严格遵守政府和国际标准。这些标准尤为重要，认证要求进一步凸显了这一需求。本文的目的是概述综合审计模型在综合癌症中心的应用。该模型是用于审计调查的追踪方法的修订版，旨在使审计活动与UNI EN ISO 9001:2015以及联合委员会关于质量、患者安全和临床风险管理的标准保持一致。使用综合审计模型，在2022年至2023年期间共进行了7次追踪，对31个科室进行了审计。每次审计询问都有记录、分类，并与国际标准化组织（ISO）和联合委员会国际部（JCI）的标准进行交叉引用。不符合项和观察结果发生率最高的领域与相关标准进行了系统关联。随后，对所得结果进行了全面分析。综合审计模型允许跨临床路径进行系统的数据收集，揭示患者护理中普遍存在的问题和改进领域。通过将确定的主题与ISO和JCI标准进行对照，评估了对国际准则的遵守情况，使各科室了解其当前状况和改进领域。总体而言，被审计方和审计人员都对该方法和持续培训表示满意，强调了其在促进协作、改善时间管理和促进遵守认证标准方面的有效性。该研究突出了该方法在监测科室活动以及遵守应用于肿瘤学环境的临床路径和国际标准方面的有效性。采用这种方法进行的审计对影响患者护理和临床治理的关键领域进行了全面评估，有助于全面了解服务提供情况。
