Typical Agenda for Certification Audit
Presentation of structure and range of services of the hospital in general and of the department of gynaecology in particular
a) Informations on the owner of the hospital and medical services in the region
b) Main points of interest and planned projects
c) Short description of the departments of core partners
Presentation of the structure of the endometriosis centre/-clinic
a) Position in relation to other areas of interest at the department
b) Present situation and planned developments. Implemetation of a network etc.
Discussion of unsolved questions from the questionnaire
a) Step by step discussion of the questionnaire items
b) Clarification of open/unclear issues. Especifically during recertifications the last notes and nonconformitis will be reviewed again.
Discussion with some core partners, e.g.
a) Anaesthesiology: pain management acute and chronic
b) General surgery: interdisciplinary planning and implementation of operations
c) Reproductive medicine unit: description of responsibilities and treatment implenetation
The decision, which core partners will participate is left to the head of the endometriosis centre – depending also on availability.
In the case of recertification, certain core partners are only required in special cases. In advance this will be communicated in the pre-audit.
Inspection of relevant facilities of the endometriosis centre/clinic
a) e.g. out patient department
b) e.g. operating theatres
Demonstration of state-of-the-art therapy by means of review of at least 5 in-patient and 5 out-patient records. Please have records of all endometriosis patients counted in the questionnaire ready for random selection. Electronic access is sufficient.
a) Review of diagnostics and imaging procedures (ultrasound, MRI)
b) Review of surgical and pathology reports
c) Therapeutic recommendations for referring physician
Head or deputy of the endometriosis centre/-clinic is expected to be present throughout the entire audit, other partners according to availability. Time frame 4-5 hours (recertification 2-3 hours)