Criterion 1.6.3 internal audits and management review meetings

Criterion 1.6.3

The Head of the Community Health Center and the person in charge carry out supervision, performance control and performance improvement activities through internal audits and planned management review meetings in accordance with priority health problems, performance problems, risks and service development plans.

1) Main Thoughts:

a) The performance of the Community Health Center needs to be monitored regarding the level of achievement of the targets set.

b) Internal audit is a monitoring and control mechanism carried out systematically by an internal audit team formed by the head of the Community Health Center.

c) The results of the internal audit findings are submitted to the head of the Puskesmas, the person responsible for quality and the Puskesmas quality team, the person in charge of the Puskesmas efforts, the service coordinator and the activity implementer as a basis for making improvements.

d) If there are problems found in the internal audit but cannot be resolved by the Puskesmas leaders and employees themselves, these problems can be referred to the district/city regional health office for follow-up.

e) The Head of the Community Health Center and the person responsible for quality periodically conduct management review meetings to discuss customer feedback, customer complaints, internal audit results, performance assessment results, changes to the process of implementing the Community Health Center efforts and Community Health Service activities, changes to the quality policy if necessary, and discussing the results previous management review meetings, as well as recommendations for improvement.

f) The management review meeting is chaired by the person in charge of quality.

2) Assessment Elements:

a) The Head of the Community Health Center forms an internal audit team with a clear description of duties, authority and responsibilities (R).

b) An annual internal audit program plan is prepared which is equipped with terms of reference and internal audit activities are carried out in accordance with the plan that has been prepared (R,D,W).

c) There is a report and feedback on the results of the internal audit to the head of the Community Health Center, the quality team, the audited party and related units (D, W).

d) Follow-up is carried out on the findings and recommendations from the results of the internal audit, both by the head of the Community Health Center, the person in charge and the implementer (D, W).

e) The Head of the Community Health Center together with the quality team plans a management review meeting and the management review meeting is carried out with the agenda as stated in the Main Ideas (D,W).

f) Recommendations resulting from management review meetings are followed up and evaluated (D,W).