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Process modeling of internal audit in healthcare center

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DOI: 10.1016/j.kontakt.2015.08.006

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Original research article

Process modeling of internal audit in healthcare

center

Vladimír Bolek a,*, Jana Filanová a, Iveta Ondrášová b, Jana Martinková c

a
University of Economics in Bratislava, Faculty of Business Management, Department of Information Management,
Bratislava, Slovak Republic
b
University of Economics in Bratislava, Faculty of National Economy, Department of Applied Informatics and
Computing Technology, Bratislava, Slovak Republic
c
Trnava University in Trnava, Faculty of Health and Social Work, Department of Nursing, Trnava, Slovak Republic

article info abstract

Article history: This scientific paper compares the definitions of an audit of domestic and foreign authors.
Received 17 February 2015 The authors determine the elemental substance of the definition, namely that it is a
Received in revised form systematic evaluation of the audited object based on pre-defined rules, norms and standards
19 July 2015 for the area.
Accepted 18 August 2015 The fundamental aim of the scientific paper is to propose and then optimize the model of
Available online 28 August 2015 process of internal audit on the quality of services in a health facility. The process model of
internal audit has been created by the method – Event-driven Process Chain by help of the
Keywords: modeling tool – ARIS Express. The main objective of the scientific paper has been achieved by
Modeling implementing a number of scientific methods. As a result, a model for internal audits in the
Optimization health facility has been created and segmented into three areas and subsequently opti-
Process mized. The audit activities are the main diagnostic tool of top management and acts as
Audit evaluation and feedback that provides information about the status of the quality of medical
Health facility equipment and processes taking place in it. Audits represent an independent source of
Auditing information and cover all the processes that make up a quality management system.
Audit errors Nowadays, the auditing process is considered the largest and most widely used manage-
ment tool for determining the level of quality management system.
# 2015 Faculty of Health and Social Studies of University of South Bohemia in České
Budějovice. Published by Elsevier Sp. z o.o. All rights reserved.

determine the nature of the audit. Lee defined the audit as a

Introduction
Since the establishment of the concept of audit, we have been
faced with different definitions that try to more or less
way where the auditor assures the auditee of the quality, and
condition or state of the subject that was examined by the
auditor. The need for such an audit arises because the auditee
has doubts or is unsure of quality, condition or state of the

* Corresponding author at: University of Economics in Bratislava, Faculty of Business Management, Department of Information Manage-
ment, Dolnozemská cesta 1, 852 35 Bratislava, Slovak Republic.
E-mail address: vladimir.bolek@euba.sk (V. Bolek).
http://dx.doi.org/10.1016/j.kontakt.2015.08.006
1212-4117/# 2015 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier
Sp. z o.o. All rights reserved.
 kontakt 17 (2015) e154–e162
matter and is not capable to get rid of these doubts or
uncertainties [1]. Silvoso conceives an audit as a systematic
process of objectively obtaining and evaluating evidence
concerning the information on economic activities and events
in order to determine the measure of agreement with the
established criteria and communicate the results to the
stakeholders [2]. Arens et al. claim that the audit is the
evidence collection and evaluation of information for the
purpose of determining and reporting the degree of correlation
between the information gathered and set criteria. The audit
should be conducted by a competent and independent person
[3]. The following is the definition of audit based on excerpting
knowledge of domestic theoretical background in terms of Act
no. 540/2007 Coll. on Auditors, Audit and Audit Oversight:
audit is the verification of The individual financial statements
or The consolidated financial statements and compliance
verification of The individual annual report with The individ-
ual financial statements or compliance verification of The
consolidated annual report with the consolidated financial
statements [4]; Kareš defines an audit as an activity – auditing,
which can be characterized as a specialized profession –
oriented for multilateral and comprehensive examination,
qualified evaluation of the company. The company is regarded
as a dynamic object with a definite audit conclusion on the
purpose for which it was ordered. The purpose was formulated
by the customer and auditor undertakes to provide him with
qualified conclusions for decision-making [5]. The audit
definitions vary according to the content and orientation,
e.g. financial audit differs from audit of nursing care.
In terms of nursing care, Farkašová et al. define an audit as
the systematic assessment of the quality of nursing care with
regard to its efficiency, cost-effectiveness and ethical adequa-
cy. It is a basic technique for detecting quality [6]. This concept
of auditing is our starting point for modeling the internal
auditing process in healthcare facilities. Unambiguously, we
can clearly define the elementary substance of the audit
definition, namely that it is a systematic evaluation of the
audited subject based on pre-defined rules, norms and
standards for the area. Audit in terms of quality management
is defined as a systematic, independent and documented
process for obtaining audit evidence and evaluating it
objectively in order to determine the extent to which audit
criteria are fulfilled [7]. The quality of an audit is a tool that
helps to not only improve quality, but also to reduce costs. It
may be defined as a systematic and independent examination
to determine whether quality activities and related results are
consistent with the intended purpose and whether those plans
were implemented effectively and are suitable to achieve
specific objectives. The term quality management system
means an organizational structure, procedures, processes and
resources necessary for the implementation of quality
management [8]. An important milestone in the development
of quality management was the publication of ISO 9000 in 1987
by the International Organization for Standardization. Stan-
dards marked the start of a journey to excellence and were
effective means for improving work within the organization.
They did not deal with the technical requirements for
production and processes, but only system requirements =
Quality Management System. QMS are really clear instructions
for the conduct of the organization's quality. In this context,
e155
the word quality does not mean good or the best, but it is the
organization's ability to meet the needs of customers [8]. It is
important to note that nowadays, the quality of the manage-
ment system is not a luxury, but a necessity to ensure long-
term competitiveness. The former approach of quality
management in the form of checks on products/services has
nowadays changed to required systems thinking and systems
approach [9]. The term quality means a set of characteristics
that determine the degree (level) of the product, and
respectively services to meet the needs of the recipient.
Quality audits have become an essential part of the quality
policy. Providing quality services in health facilities ensures
the best possible attainable standards for healthcare. In the
Czech Republic, the Act 372/2011 Coll., On health services and
conditions of their provision in § 47, para. 3, letter b), assesses
duties on the provider to establish an internal system of
evaluating the quality and safety of the health services being
provided [10]. Quality management in healthcare facilities is
undoubtedly far more complex than in industry. It stems from
a different understanding of quality and the complexity of the
organizational system of healthcare facilities [11]. Quality of
health services means not only high material and technical
provision of the workplace, but also human access of all
healthcare staff to clients. The concept of quality of services
must be significant within the organization and become part of
the mindset of each employee [8]. Services in health facilities
are intangible and abstract. While in industry the determining
factor is the quality of the product, in healthcare, attention is
focused on the activities taking place in the relationship
between patients and healthcare professionals. A poor quality
product in the industry definitely does not have such a great
impact on the quality of the client's life as a poor customer
service provided in healthcare [11]. The audit activities are the
main diagnostic tool of top management and act as evaluation
and feedback that provides information on the status of the
quality system of businesses, organizations and processes
taking place in them. Audits are an independent source of
information and cover all the processes that make up a quality
assurance system. The auditing process is considered today as
the largest and most widely used management tool for
determining the level of quality management system. Internal
quality audits takes place throughout the organization and
covers all areas of the provided services. Internal quality
auditors are trained for this purpose. The scope and type of
training is determined by a healthcare provider. Audit results
are analyzed and demonstrably used to improve the care
provided.
Materials and methods
The fundamental aim of this scientific paper is to propose and
then optimize the model of internal auditing process,
regarding the quality of services provided in health facilities.
The main objective consists of several partial objectives. The
starting point is the excerption knowledge of domestic and
foreign literature, comparison of knowledge and a priori
information. When comparing the definitions in domestic and
foreign literature, we used important foreign publications and
scientific journals included in Scopus, WOS, WOK, Medline
e156 kontakt 17 (2015) e154–e162
and proceedings from international scientific conferences. The
key words in the creation of research were: audit, process
modeling, quality and health facility. Based on the aggregated
theoretical background, we have modeled the process of
internal audit in healthcare facilities. The model has been
subsequently optimized. The modeling process was carried
out in several phases: formulation of the task (system analysis,
process analysis, determination of requirements on the audit
process and finding variations of activities), building the model
of the examined system (modeling the set of variables,
analogous solution and process optimization), model verifica-
tion and after-treatment solution.
For creating the model of internal auditing process, we have
used the method Event-driven Process Chain (EPC) by help of
the modeling tool ARIS Express. EPC is a modeling language
used in drawing up process diagrams. As the EPC is mainly
used in the ERP system SAP R/3 and in ARIS application
designed to process modeling, it can be considered one of the
most widely used modeling methods. The essence of the EPC
method is a sequence of events and activities that produce the
desired result. The beginning and end of each chain is specified
by an event. The event is determined by certain conditions
that must be met so the process could begin and end. Any
event may be followed by several activities, or vice versa, after
any activity may follow several events, but with clearly defined
rules for the processing in the middle. Such rules are called
connectors and take the form of logical operators OR, AND, and
XOR. The main advantage of the EPC method is its simplicity
and clarity of notations, making it a widely acceptable
technique for modeling processes [12].
Approaches of the Architecture of Integrated Information
Systems (ARIS) are based on an integration concept that
derives from a full description of the processes in the
organization. The first step in creating the architecture
requires the development of a process model containing all
the essential features necessary for description of the
individual processes. Relations between views are defined
subsequently and an overall view of the process without
redundancies is created. The high complexity of the emerging
model is reduced by its distribution to the individual model
views [13].
Our own software, based on graph theory, was developed
and used for optimization and eliminating redundancy in the
audit process [14]. The (AON) network diagrams are conve-
nient for the process modeling. The process is represented by
graph G = (V, H), where V represents the set of nodes (activities)
and H represents the set of edges (relations between activities).
Next, a function t(h) is defined as the duration of a single
activity (period
edge). The aim is to find a minimum tree S for
the group of points U belonging V, U  V. The minimum tree
S = (V0 , H0 ); V0  V; H0  H connects the set of points U in such a
P
way that the total time (duration of the process) T(S) = h2Ht(h)
will be minimal. The target set U (basic activities) and the set of
Steiner's peaks (secondary/ancillary activities) are the peaks of
this tree. Finding Steiner's peaks is mathematically a very
complicated task and solution time depends exponentially on
the number of nodes in the graph G. The problem can be solved
by transforming the network (graph) to such a subgraph G0
(minimum spanning tree), which contains only the nodes of
the target set [15,16]. Finding edges connecting the target set
with minimal time can be realized by using Floyd's algorithm,
or by re-using Dijkstra's algorithm or by Prim algorithm which
finds the shortest connection from one (source) node to all
other nodes in the network graph. Then the above mentioned
reduction to the subgraph consisting of the nodes of the target
set can be performed [17].
The representation with Steiner's peaks was used in
stochastic evolutionary algorithms for the optimization of
network graphs. The mentioned representation is currently
the most effective method in terms of search space dimension
(complexity 2(N
m), where N is the number of network nodes
and m is the number of connected nodes).
Results
The software tool, called The Simulator of Connections, was
developed and used to optimize the model of internal audit.
The Simulator can use the embedded evolutionary algorithms
to optimize any network graph, being represented by
incidence matrix into the graph of the shortest connections.
The obtained graph is represented by the resultant vector
of Steiner's peaks or by resulting matrix of connections.
Scheme 1 describes the procedure for optimization of internal
audit. Entry into the Simulator consists of the incidence
matrix, which represents the internal audit model that was
designed on the basis of summarizing the theoretical
background. The model contains 29 activities. Some of them
have been eliminated in the subsequent optimization (elimi-
nated activities are described in the discussion). The incidence
matrix has the structure similar to the connection matrix with
the only difference being that, if there is a connection between
nodes i and j in the network, then there is not the logical 1 but a
positive number in the matrix position of the ith row and jth
column. The value of the number shows the evaluation of the
edge. It is based on percentage of importance of its next
activity to the edge [18]. Entered values of the incidence matrix
are then recalculated to Reciprocals in the Simulator. This
solution ensures a minimum spanning tree.
In the next step, the optimization algorithm was selected
[19], under which the Simulator calculated the resulting vector
of Steiner's peaks (Scheme 1). This vector, i.e. the output in the
form of a connection matrix is the suitable base for the model
optimization by using the EPC method in the software tool
ARIS.
The optimization of the internal auditing process in the
health facility resulted in the model of internal auditing
process in the health facility, which is shown in Scheme 2. The
model of internal auditing process consists of events and basic
activities, which are further described in detail:
Beginning of internal audit
A quality Manager shall appoint the leader of the audit team
for a particular audit. The lead auditor, in cooperation with the
quality manager, selects the members of the audit team,
unless the selection is predetermined by the quality manage-
ment requirements. Selecting the audit team shall be held
according to their professional competence within the audit
area. The auditors shall not examine their own work. The lead
 kontakt 17 (2015) e154–e162
Scheme 1 – The procedure for optimizing the internal auditing process using the optimization software tool Simulator.
auditor in consultation with the members of the audit team
sets goals, object and criteria of the audit and holds an initial
interview with the management of the organization where
they agree on basic conditions of the auditing. He shall require
access to relevant documentation and records, review the
documentation of the organization, and negotiate the criteria
for confidentiality. The lead auditor shall no later than 14 days
before the week of the audit agree the exact date and time
when the audit starts, specify the scope and other require-
ments related to the audit. If the auditee enters any objections,
the lead auditor shall deal with the issue with the managers
before performing the audit.
Review of supporting documentation
Prior to the opening the audit, the Lead auditor requests the
supporting documentation regarding the quality management
system, audited processes, and organizational unit or service
provided. It is important that auditors review the compliance
e157
of documentation with the audit criteria, taking into account
the goals and the audit's scope. Reviewing documentation
shall include documented procedures, records and reports
from previous audits.
Preparing for activities carried out on the spot
The lead auditor shall prepare an audit plan based on available
information. The plan shall facilitate the creation of the
timetable and the overall coordination of the audit activities.
Based on the given process maps of the organization, the area
to be audited has to be determined before preparing the audit
plan. Afterwards, the lead auditor and the team members shall
come to an arrangement about the audit procedure and assign
the individual tasks to each of the members. According to the
assignment and schedule, they prepare the appropriate and
necessary documents for the rapid course of the audit and
required information records, i.e. questionnaire and various
audit forms for evidence, findings and so on.
e158 kontakt 17 (2015) e154–e162

Scheme 2 – Process model of internal audit in health facility.

The course of the audit – auditing activities on the spot
The lead auditor agrees the audit program with the owner of
the audited process and introduces the members of the
audit team to him. He informs all concerned about the
intention and care to meet the timetable of the audit. The
audit shall collect information on the objectives, subject
matter and criteria of the audit. The members of the audit
team shall record information in writing, because only this
form is acceptable evidence of an audit. The results of the
evaluation of the gathered evidence shall be compared with
the audit criteria and shall be verified information. The
auditors shall record all disparities, controversial issues and
clarify potential changes in the scope of the audit and the
audited entity.
The audit team shall begin audit with the assumption that
the quality system is okay and look for objective evidence of
compliance. The auditors shall rigorously not only focus on the
audit scope but also monitor other activities. All qualitative
and quantitative information, records and data relating to
 kontakt 17 (2015) e154–e162
actions based on observations are objective evidence of
conformity or nonconformity. Nonconformity is actually a
failure to fulfill a specified requirement in the quality
management system [7].
The audit team, using active communication techniques,
collects, obtains, gathers, evaluates and analyzes information
of all kinds, which are based on objective evidence. In auditing,
the auditor shall actively receive information, e.g. by listening,
reading, watching, mapping and monitoring surrounding, but
speaking as little as possible. He shall answer only the asked
questions accurately and professionally. Auditors shall review
the information from the interviews and also from other
independent sources, i.e. from other currently unchecked
processes. The members of the audit team shall closely
monitor:
– persons – competence, responsibility, understanding tasks;
– documentation – compliance with standards and system
standards;
– machinery, apparatus, equipment, technology;
– environment – working environment and conditions for
staff;
– measurement instruments – technical and functional
status, and calibration status.
In auditing therapeutic procedures, the audit team focuses on:
– timely initiation of targeted treatment;
– effective pharmacotherapy;
– differentiated care;
– comprehensive care;
– maximum gentleness of treatment;
– proportionality of costs;
– cooperation of departments in complex healing processes.
In auditing nursing care, the audit team focuses on:
– checking nursing documentation;
– ensuring the personal hygiene of patients;
– availability of nurses in emergency situations;
– observation of nurses at work;
– preventing injuries and bedsores;
– consistent administration of medication as prescribed by
the physician;
– suitable diet of the patient;
– adequate daily routines for patients;
– use of time of nurses for the benefit of the patient and
hospital;
– appropriate communication of nurses with patients;
– respecting qualifications of nurses and their comments;
– standards compliance;
– monitoring and evaluation of the overall quality of nursing
care.
The result of the audit findings can be any of the following
states:
a) compliance;
b) discrepancy;
c) given the opportunity for improvement.
e159
Auditors record all audit findings. The purpose of the audit
is not to find nonconformity at any price, but to find out the
actual state. The nonconformities are identified in relation to
the specific requirements of standards and other related
documents, according to which the audit is performed. The
categorization of nonconformities:
– small (insignificant), which do not jeopardize the security
and functionality of the system; they can be removed
immediately or until the next audit;
– large (essential, systemic), which can cause a significant
problem in the context of internal or external quality
assurance. Thus, it means a complete absence or failure
of any element of quality management.
The auditors check whether the observed nonconformity
occurs too frequently in conjunction with a process, proce-
dure, organizational unit or a person. They focus attention on
situations that directly endanger the quality of services and
patient safety. Before the final interviews, the audit team shall
review the findings and compare them with the aim of audit,
approve the conclusion of the audit, prepare recommenda-
tions to the findings and discuss the need for subsequent
audits. The final conversation shall be held by the lead auditor,
who presents the findings and conclusions of the audit, so that
all stakeholders can understand. The head of the audited
section confirms, with his signature, that he was familiar with
all the recorded results of the audit. He himself will decide
whether to attach his opinion. Any discrepancies between the
audit team and the auditee are consulted and, if possible,
resolved. The lead auditor shall notify the auditee about the
audit findings, recommend improvements, and provide
information regarding how the audit report will be distributed.
The preparation, approval and distribution of the audit report
Based on the findings of the audit team, the lead auditor shall
prepare a written audit report until the agreed date after the
final meeting. The report is approved according to the audit
program, distributed to the recipients – the audited health
facility. It contains the aim and subject of the audit, audit
criteria, evaluating the extent to which the audited fulfills the
requirements for achieving the objectives, findings, conclu-
sions and suggestions for improvement. In case the audit
revealed discrepancies, the head of the audited unit shall
propose corrective measures upon receipt of the audit report.
The measures serve to eliminate discrepancies and should be
sent together with the date of their removal using the ‘‘record
of non-compliance from audit’’ to the lead auditor for each of
the non-compliances separately. If a representative of the
audited unit does not propose corrective measures without
proper justification, the quality manager shall decide on
further steps. If the audited unit fails to meet the deadline of
remedies, the head of organizations deals with the problem.
The top management shall also determine preventive actions
to eliminate the causes of nonconformities in order to prevent
their reoccurrence. In the report of the audit, the lead auditor
identifies further reference documents by which it was
audited, identifies the audit team members and representa-
tives of the audited unit. The lead auditor is responsible for the
e160 kontakt 17 (2015) e154–e162
comprehensiveness, accuracy and completeness of the audit
report. After discussion, the report shall be signed by the audit
team and by a representative of the audited department.
Audit conclusion
The audit can be considered completed when all activities
have been completed according to the audit plan, and the audit
report has been distributed. Documents relating to the audit
shall be maintained and kept in accordance with the
procedures of the audit program and the relevant statutory
and regulatory requirements. Verification of implementation,
efficiency and effectiveness of remedial measures may be part
of a follow-up audit [7].
Implementation of follow-up audit
In case that the discrepancies occur again, complaints repeat
and there is a significant quality deterioration, then the audit
team shall carry out a follow-up audit. The new audit shall
check the implementation of corrective measures that were
recommended to perform during the previous audit.
Discussion
The requirements of patients on quality of healthcare are
constantly increasing. It is in society's interests to take into
account the requirements and ensure the satisfaction of
clients or patients with the healthcare. This objective can be
met by such a realization of everyday work of medical staff,
which will be based on the latest scientific knowledge, will
have their standards, criteria for quality assessment and will
be adequately accepted in the healthcare system. The quality
of work of all the medical staff will be the primary factor in the
evaluation of any health facility.
Quality assurance in health facilities depends on the
maintenance and continuous improvement of established
quality management system. It is known that sufficient funds
for sustained improvement of the quality management
system are absent. Nevertheless, we believe that medical
staff will approach the implementation of quality policy
responsibly and are aware that it is a priority of satisfaction of
the patient or client.
The mean to achieve a continuous improvement of quality
of healthcare is the quality management system. This issue
was briefly zoomed in this article.
A quality audit is the tool for verifying the functionality of
the quality management system. In the process of quality
audit, the cyclic model of Plan-Do-Check-Act (PDCA) can be
applied. Applying the methodology is described as follows:
Plan: Establish the objectives and processes necessary to
achieve results in accordance with the requirements of
customers or patients and policy of organization. Do: imple-
ment the required processes. Check: monitor and measure the
processes, control the results according to the specified
requirements and report on the results found. Act: take
actions based on the results for the continuous improvement
of process performance. The main objective of the application
of this methodology is the creation, building up, monitoring
and continuous improvement of processes within the organi-
zation. PDCA cyclic model, which is the cornerstone of quality
management, also applies to the processes of describing the
care of patients [20]. Deming model is recognized worldwide,
confirming its applicability abroad in continuous quality
improvement of health facilities [21].
Using scientific methods of modeling, optimization tools
and software ARIS, process model of internal audit in health
facility without redundancies has been created. The opti-
mization has allowed achieving, for example, eliminating
the process of evaluating auditors and audit team leaders,
which consists of several activities (determination of
personal qualities, knowledge and skills necessary to meet
the needs of the audit program; determining evaluation
criteria, selection of appropriate evaluation methods; im-
plementation of review). Also eliminated were the activities
regarding the selection of the working language and
language of the audit report, logistical measures and
confidentiality issues.
After optimization, internal audit model has been designed
in a way to allow the complex process logically divided into
three separate processes:
1. Internal audit preparation process.
2. Internal audit execution process.
3. Internal audit evaluation process.
The advantage of this division is greater clarity and
legibility. Another advantage is the possible use of the
preparation and evaluation processes of internal audit in
any organization, while the process of an internal audit can be
variable.
Model of internal auditing process can help to eliminate
redundant steps and activities when audit is ordered in health
facility.
However, except complying with the various tasks and
activities in the audit process, the organization and the
auditors can make a number of errors that need to be pointed
out:
– formalism (audit done as an obligation, audit done just pro
forma, etc.), pretending auditing and auditing only for the
certification, it causes damages to the management system
and does more harm than help;
– inability to appreciate the importance of audits by the top
management (delegation of authority and responsibility for
the quality system to the lower branches);
– bureaucracy in audits and in corrective measures (exagger-
ated scope and content of the audit);
– complicated procedures (complicated way of conducting
audits, which discourages auditee and auditors);
– insufficient motivation of auditors (audit as unpleasant
obligation, weak financial motivation of the auditors);
– unequal criteria when auditing Management Responsibility
(fear of revealing discrepancies);
– punishing for audit findings (misunderstanding the princi-
ple of continuous improvement – audit as an incentive to
sanctions leading to the scheme ‘‘sentence – fear – a lie’’);
– insufficient planning (incomplete audit plans do not cover
all workplaces);
 kontakt 17 (2015) e154–e162
– lack of emphasis on the effectiveness of corrective actions
(learning from mistakes, repeating the same findings);
– benevolence of the top management (shifting the terms of
corrective actions due to a lack of labor discipline of
managers);
– insufficient findings (absence of observed discrepancies due
to the threat of the findings when auditing the workplace – a
false friendship within the organization, firm, enterprise);
– strict adherence to the plan (attempt to hide the discre-
pancies which are not directly listed in the audit plan,
though they are known by the management);
– insufficient readiness of auditors (lack of trainings especially
in assertiveness and psychological aspects of the audit);
– creating barriers between departments (audit findings are a
source of gossip and ridicule addressed to the auditee);
– phasing out audits (loss of interest of top management,
which leads to a decrease in efficiency of audits);
– insufficient emphasis on prevention (the non-compliance
has not had a negative impact, so it is neglected).
Unlike the control audits aimed at verifying allegations of
illegal management of companies, results of internal audits
must not be penalties on persons. The quality of healthcare is a
dynamic, multi-dimensional process. In this world, there is
great interest in the quality and its development. Globalization
has resulted in the fact that no country can afford to be
indifferent to the concept of quality. Without understanding
the basic principles and philosophy of quality, without radical
reconstruction of thinking, it is not possible to handle this role
in our health facilities. From the position of quality manager, it
is necessary to enforce at the top management of health
facilities to deal with the results observed in research and
apply them in practice. Leadership must strongly promote
educational activities for the staff of health facilities in the
field of quality management and audits to deepen their
knowledge level and correct application in practice through
professional seminars, courses and workshops. It is required
to use workshops for staff of health facilities to raise the level
of awareness of the audits with reference to the severity of
their implementation and benefit to the organization. It is
necessary to pay continuous attention to the qualification and
professional growth as well as improving the occupational
skills of the staff, according to the requests for not only their
current but also the perspective needed performance. To a
greater extent, staff of health facilities should be involved in
the preparation of audit and its implementation. And then
their demand and communication with the auditors may be
helpful to clarify the state, some problems on site of audit and
obtain the knowledge about disagreements and deviations
with the requirements of the quality management system. It
would be necessary to develop motivational possibilities and
types of remuneration that could be used in practice for
encouraging the staff of health facilities to improve the quality
of healthcare services. The management is required to
establish criteria for measuring the proportion of participation
of individual staff or entire team in the creation of quality. The
criteria are to be based on audit findings, which are one of the
benchmarks of quality. The attention of the organization's
management should target the factors that according to the
results of research would contribute, to the greatest extent, to
e161
the improvement of nursing care. This would meet the
expectations of patients to achieve their satisfaction. The
following factors require the greatest attention: increasing the
knowledge and skills of nurses in the usage of information
technology, ensuring sufficient medicines and special materials
on departments, better financial valuation of nurses, increased
quality of material and technical equipment, better diet for
patients, and more detailed information for patients about the
method for treating their disease. Top management of the
organization is to create sufficient space for the discussion with
the staff of health facilities about such professional issues that
are essential to the quality of healthcare.
Conclusion
For the purpose of achieving the quality of services the
systematic verification of nursing care has strategic role in
healthcare. Achieving a high level of quality regarding
healthcare services requires implementing a continuous
quality management system, including the audit activities
[22]. The scientific paper compares the definitions of the audit.
By applying the scientific methods of process management,
modeling and optimization, model of internal audit in
healthcare facilities has been designed, so the main objective
has been fulfilled. EPC, i.e. modeling language used in the
compilation of process diagrams and modeling tool ARIS
Express were used in the process of modeling. Decomposition
of processes and plotting them in diagrams allow understand-
ing of processes, the sequence of steps, including alternative
routes of transition the process, identifying problematic areas,
gaps, deficiencies and flows. Based on the depth analysis of
individual processes of audit, a model of internal audit process
has been proposed in aggregated form. The model has been
segmented into three areas: preparation process, execution
process, and evaluation process of internal audit. The
scientific paper also points out possible errors that can occur
during an internal audit. The model of internal audit process
could help the health facility to eliminate redundant steps and
activities in the audit control, which ultimately has a positive
impact on the quality of services and the competitiveness of
the health facilities.
Conflict of interest
The authors have no conflict of interest to disclose.
Acknowledgement
The research and the paper were supported by the Scientific
Agency VEGA through financial support of the Project No. 1/
0336/14 at the University of Economics in Bratislava.
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