Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

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Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

14.0 Unannounced Inspection Flowchart

Plan Programme

Environmental Scan:

Stakeholders & External

Information

Prior to Inspection Year

Plan

Programme

Prioritise Themes & Areas for Core Inspections

Balance Programme

Consider:

Areas of Non-Compliance

Infection Rates

Trust Information

January/February

Schedule Inspections

Prior to Inspection

Identify & Prepare Inspection Team

Episode of Inspection

Day of Inspection

Day of Inspection

Inform Trust

Carry out Inspection

Is there immediate risk

requiring formal escalation?

NO

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

Day of Inspection

Feedback Session with Trust

14 days after

Inspection

28 days after

Inspection

Preliminary Findings

disseminated to Trust

Draft Report

disseminated to Trust

NO

Does assessment of

the findings require

escalation?

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

Reporting & Re-Audit

14 days later

Within 0-3 months

Signed Action Plan

received from Trust

Is a Follow-Up required?

Based on Risk Assessment/key

indicators or Unsatisfactory Quality

Improvement Plan (QIP)?

YES

Invoke

Follow-Up

Protocol

Process enables

only 1 Follow-Up

NO

Open Report published to Website

YES

Is Follow-Up

satisfactory?

NO

DHSSPS/HSC

Board/PHA

33

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