Performance Improvement / Quality
Audits and Surveys
Each month, appropriate staff are assigned audits and surveys to complete.  Although the focus of each of these audits vary, the intent of each is the same and that is to verify and examine in detail accuracy in information and processes throughout the ambulatory patient care experience. 
The purpose of performance audits is to help oversee and evaluate operations. Audits answer the following basic questions:
  • Is the practice site meeting the standards set forth by Joint Commmission and the organization?
  • Is the practice site meeting the quality and safety needs of the patient/family?
  • Is the practice site meeting the expectations of the organization related to safety and quality?
For clinics, audits serve as an educational tool to identify areas needing corrective action and/or staff education. 
It is important that action be taken immediately upon identifying an area falling below an acceptable range.
Audit/Survey Information Sharing
In the Ambulatory Care setting, the following process will be used to learn and grow from the audit and surveys conducted throught the ambulatory setting:
  1. The oversight of Practice Site audit and surveys is the ultimate responsibility of the Practice Site Administrative Director/Manager/Coordinator.
  2. Scores for each Practice Site will be shared in the weekly Management meeting the Tuesday following the audit or survey due date.
  3. For scores less than 90, the Practice Site will be responsible for submitting an action plan within 3 days of receiving scores.
  4. Action plans will be shared in the appropriate Management meeting.
  5. At any time, Practice Sites are subject to a follow-up survey to verify compliance with the corrective action plan submitted.  The results of this full or focused survey will be shared in the appropriateManagement meeting. 

Hand Hygiene Audits
Due Date:
Last Friday of each month
Using the entry form below, please submit at least 30 hand hygiene observations, per Practice Site, each month.

 Hand Hygiene Audit Form


Additional Audits/Surveys

Please click on the survey link below that you would like to complete.


  1. Storing of medical equipment, devices, and supplies - due on the first Monday of each month on all identified patient care storage areas



Audit Reports