Information for clinical and frontline staff

The audit process

Audits are a regular and supportive process to ensure services provide safe, quality care. They are not designed to test individual staff members but to review the systems and processes your organisation has in place.

What to expect during an audit

Audits are conducted by a team of qualified auditors from a Designated Auditing Agency. The length of an audit depends on the size and complexity of your service, but typically ranges from one to five days.

The audit process generally follows these steps:

1. Pre-audit planning: Your facility receives notice of the audit and prepares relevant documentation. Staff are informed about the upcoming visit.
2. Opening meeting: The audit team introduce themselves, outline the schedule and process, and answer initial questions from management and staff.
3. Document review: Before arriving on site, the audit team reviews your organisation’s policies, procedures, and other relevant documentation to understand your systems and prepare for the visit. Once on site, auditors focus on reviewing clinical records, care plans, and other documentation related to the delivery of care.
4. Observations and conversations: Auditors will observe the delivery of care and speak with staff, consumers, and their whānau/families.
5. Closing meeting: All available staff are invited to attend. The audit team share their initial findings and next steps.
6. Final report: A detailed report is sent to your organisation, including observations made during the audit, commendations for good practice, and findings that identify areas requiring improvement.

Who is on the audit team?

An audit team is typically made up of:

• Lead Auditor: An experienced healthcare professional who coordinates the audit and has extensive knowledge of the Ngā Paerewa Standard.
• Clinical Auditor: A registered healthcare professional, often a nurse or allied health professional, who focuses on clinical care standards and understands your day-to-day work.
• Consumer Auditor: A person with lived experience of using health and disability services, who provides a consumer perspective. Consumer auditors are only involved in certification audits for residential disability and mental health services.

In some cases, depending on the type of service being audited, a Technical Expert may also be involved. This is a health professional with recent experience in the specific service area (eg, maternity, forensic, addiction, surgical, or hospice services). They do not act as auditors but may attend on-site to offer specialist advice.

How auditors interact with staff

Auditors are healthcare professionals who understand the pressures of a clinical environment. Their goal is to have respectful, professional, and supportive conversations to understand how you and your team provide care. 

You can expect auditors to:

• Introduce themselves and explain their role.
• Ask if it is a suitable time to talk, and be flexible if you are busy with a consumer.
• Show genuine interest in your work and acknowledge your expertise.
• Maintain appropriate distance and respect consumer privacy during observations.
• Provide positive feedback when they observe good practice.
• Keep all conversations confidential and professional.

You're encouraged to speak openly and honestly with auditors during their visit. You don’t need to wait for an auditor to approach you. If there's something you'd like to share — whether it's a positive experience or an area where you think things could be improved — feel free to initiate a conversation at any time. 

As conversations with auditors are confidential, you can feel comfortable raising concerns or giving constructive feedback. Your insights are valuable and help strengthen the quality of care and support provided.

What auditors don’t focus on

Auditors are here to look at how the service is performing overall — they’re not assessing individual staff or handling personal complaints. 

Audits aren’t the place to raise concerns about individual behaviour or interpersonal issues. Instead, the focus is on how well our systems and processes meet the Ngā Paerewa Health and Disability Services Standard, and how that translates into quality care for consumers. 

If you do have concerns about a colleague’s conduct, it’s best to raise these through your usual internal reporting channels or HR processes.

Typical questions auditors may ask

Auditors ask straightforward questions related to your everyday work to understand how theory is put into practice. Below are some examples.

About your role and responsibilities

• Can you tell me about your role and what a typical day involves?
• How do you prioritise tasks when you are busy?
• Who would you report to if you had a concern about a consumer's wellbeing?

About consumer care

• How do you involve consumers and their whānau in care planning?
• Can you describe the process you would follow if a consumer had a fall?
• How do you ensure a consumer's privacy and dignity are respected?

About policies and procedures

• Where would you find the procedure for infection prevention and control?
• What training have you recently completed that helps you in your role?
• If you were unsure about a procedure, what would you do?

Guidance for participating in an audit

Your participation is highly valued and contributes to improving the quality of care.

• Be yourself: Speak naturally about your work. Auditors want to understand your real experiences.
• Share your knowledge: You are the expert in your role. Be confident in sharing what you know.
• Ask for clarification: If you do not understand a question, please ask the auditor to rephrase it.
• Focus on care: Consumer care always comes first. Auditors will understand if you need to pause a conversation to attend to a consumer.
• Support your team: Audits are a team effort. Help cover for colleagues who are speaking with auditors and share your experiences with each other.

Support and resources

If you have questions or concerns about an audit, help is available.

• Your Manager or Supervisor: They can answer questions about the specific audit at your service.
• Quality Team: Your organisation's quality or clinical governance team will have a deep understanding of the audit process.
• HealthCERT: For questions about the certification process, email the certification team at [email protected].