Healthcare Providers FAQs

Audit is an objective, independent and evidence-based assessment of how effectively hospitals are managing their waiting lists. Audits play a key role in providing assurance that waiting lists are being well managed and in line with national protocols

Audit outcomes are a key driver in promoting standardisation of hospital waiting list management practices nationally and help hospitals achieve good practice in waiting list management. Well managed waiting lists support the delivery of timely and equitable access to care for patients. Audits  also help to inform protocol development through our findings and recommendations. 

Hospitals for audit are selected based on the scope and objectives of the audit programme. Selection criteria are employed from which the applicable hospitals for audit are chosen. 

Yes, hospitals selected for an audit receive an intention-to-audit letter generally 3 weeks prior to the scheduled audit date which provides details about the upcoming audit, scheduled dates and audit requirements. 

A member of the Audit Team will liaise with the Scheduled Care or nominated Lead to ensure the necessary arrangements are in place prior to the audit. Patient records for review will be identified to the hospital normally 2 weeks prior to commencement of the audit to facilitate the gathering of required information. You may also be asked to provide or complete some supporting documentation in advance.  

An audit typically takes between 2 to 5 days, depending on the scope of the audit programme. 

• An opening meeting will take place with the Audit Team and the Scheduled Care or nominated Lead to outline the on-site audit process
• On-site audit checks involve the review of the Patient Administration System (PAS) and healthcare record against the random samples. The Audit Team will only access information that is necessary and within the scope of the audit
• We may also need to review local hospital Policy’s and SOP’s
• During the course of the audit, we will communicate any issues and will provide feedback on the progress of the audit. We also invite any questions or comments and will address any concerns you may have
• The Audit Team will hold a close-out meeting with Scheduled Care or nominated Lead to discuss the initial audit findings and to outline next steps of the audit process.  Other hospital representatives may attend this meeting, if deemed appropriate

A draft audit report will be issued to your hospital generally within 3-4 weeks of completion of the audit. The hospital is required to review the findings, agree recommendations and provide a formal response within 3 weeks of receipt of the report.   On receipt of hospital response and sign off, the approved reports are issued.

No, audit reports are generally not published publicly. Hospital reports are issued to the individual hospitals and key stakeholders i.e. Regional Executive Officer (REO), HSE Scheduled Care, Access and Integration, Scheduled Care Performance Unit Department of Health (DoH) 

The ERI process follows a standardised referral pathway. Through a referral process AQA will take receipt of reported issues requiring further examination where a more in-depth analysis of waiting list data and/or operational processes is required. 

AQA will accept referrals from departments within the NTPF and independent external stakeholders including individual hospitals, health regions, HSE and Department of Health (DoH).   

An ERI referral form can be obtained by contacting ERI@ntpf.ie 

AQA carry out an initial assessment of the information provided in the referral form to determine if the referral is valid and warrants examination. We may need to liaise with the referrer if additional information or clarification is required regarding the reported issue in order to progress the examination. 

An examination involves a detailed analysis of the waiting list data and/or operational processes reported for review by the referrer. Decisions and outcomes are based on facts and data derived from the data analysis process. 

Upon completion of a detailed review of a reported issue, AQA will liaise in the first instance, with the hospital Scheduled Care and/or nominated Lead, and will provide the details and outcome of the review. Also, if required, a data report will be issued for immediate review and corrective action where necessary. Associated prescribed protocol guidance will be included for reference. 

If AQA are satisfied with the hospital response received and the commitment to implementing corrective action/improvement to operational process the ERI will be closed, and notification will be communicated in writing to the hospital. 

Where required, ongoing monitoring and surveillance will continue until the hospital has actioned the identified issue. Progress data reports may be issued while the ERI remains under review to support the hospital management of same. Once, we are satisfied that the issue has been resolved the ERI will be closed.

During an ERI examination, a number of issues may arise where escalation may be required. Formal notification will be issued to the hospital if this is the case as to the reasons for this and required actions for rectifying the issue. In addition, relevant key stakeholders are informed of the nature and impact of the outstanding issue, required actions and the final outcome. Also, an ERI may progress to audit in instances where information identified may require a more comprehensive review. 

Yes, AQA will notify the referrer in writing once the ERI examination has been completed and closed. We will return the referral form with details regarding the outcome of the examination undertaken recorded in the outcome section at the bottom of the referral form.