Regulation on Auditors

Preamble

• o The NIAZ has the goal of contributing to the assurance and improvement of quality of care in health care organisations.
• The NIAZ realises this by developing quality standards and, at the request of health care organisations, periodically investigating them according to a set procedure of previously established standards. If conformity appears to exist with the set requirements, the health care organisation is granted an accreditation status.
• The NIAZ is a confidential institute which, because of the very nature of its activities, has to meet high requirements concerning integrity and confidentiality. In the NIAZ, sensitive information about organisations and persons is exchanged, about which public disclosure or knowledge by third parties could cause damage for the NIAZ and for those involved. Some information about the NIAZ itself also requires confidentiality, in relation to the competitive environment in which the NIAZ operates.
• For the activities described for this, the NIAZ uses persons who have the required knowledge and expertise at their disposal, who, on a voluntary basis and with the approval of their employers, make themselves available and are not engaged by the NIAZ by means of an employment contract. These persons are referred to as ‘auditors’.
• This regulation establishes the most important rights and obligations of an auditor. The working activities of an auditor include participating in the audit processes, also working activities for the purpose of the NIAZ’s projects and committees, amongst other things, regarding developing standards and issuing quality declarations.

1. Profile of the auditor

1.1. The auditor meets the following requirements:
1.1.1. fulfills – or has fulfilled – one of the following positions within a health care organisation: member of the management or executive board, medical specialist, manager, paramedic, nurse or staff member in quality care;
1.1.2. in relation to the status of auditor, has support from the management or executive board of his/her own health care organisation;
1.1.3. subscribes to the mission, vision and values of the NIAZ;
1.1.4. is familiar with the NIAZ reference framework, has followed the NIAZ auditor training programme and meets the assessment criteria for that purpose..

1.2. The auditor has the following competencies and skills:
1.2.1. Objectivity
1.2.1.1. is capable of gathering relevant information through looking at processes with an all-embracing eye, without losing sight of the details;
1.2.1.2. is capable of arriving at the right judgement on the basis of a good analysis, in which the conclusion is based on observations/facts during the audit;
1.2.2. Communication skills
1.2.2.1. has the skill to conduct interviews and is an active listener;
1.2.2.2. is capable of communicating in an effective manner on various levels with people in various positions and disciplines within the organisation and to adapt himself/herself accordingly;
1.2.2.3. has a good power of expression, both in writing as well as orally;
1.2.2.4. is conscious of the influence that his/her actions have and takes this into account in his/her manner of communication;
1.2.2.5. presents himself/herself as a member of the audit team.
1.2.3. Integrity
1.2.3.1. deals carefully and respectfully with the observations and findings;
1.2.3.2. complies with the obligation of confidentiality.
1.2.4. Cooperation
1.2.4.1. is capable of working in a team;
1.2.4.2. recognises the role of chairperson and survey manager.
1.2.5. Learning attitude
1.2.5.1. is open for feedback and adopts a learning attitude.

2. Beginning and end of an auditorship

2.1. The auditor who is engaged by the NIAZ as such is registered in the auditor pool. For this purpose, he/she signs a Declaration of Registration in the Auditor Pool, in which he/she commits himself/herself to the provisions of this regulation as well as other relevant rules of the NIAZ.

2.2. The NIAZ can end the auditorship at all times substantiated with reasons (remove him/her from the pool) by means of a written notification to the auditor.

2.3. The auditor can end the auditorship at all times and without submitting reasons, by means of a written notification to the NIAZ.

3. General obligations auditor

3.1. In consultation with and in accordance with the provisions of this regulation, the auditor will be available for the working activities as described in this regulation. He/She is committed to the investment of time as agreed within the NIAZ for the preparation, implementation and reporting on an accreditation programme and the planning involved in it.

3.2. The auditor fulfils his/her tasks in accordance with the scrupulousness which the NIAZ may expect from a good auditor and with the NIAZ’s valid guidelines and regulations. At the very least this includes the following behavioural code:
3.2.1. behaving in the organisation as a guest;
3.2.2. refraining from giving his/her own opinions, information about his/her own experiences, advice or judgement values;
3.2.3. respecting the agreed time schedule;
3.2.4. refraining from accepting tokens of individual goodwill (presents/promotional gifts);
3.2.5. refraining from offensive behaviour.

3.3. The auditor will inform the NIAZ on time and adequately about changes in his/her position, a possible conflict of interests, possibly no longer meeting the profile requirements of an auditor or any other matters he/she should understand that could be of essential influence on being able to function as an auditor.

3.4. The auditor successfully participates in the programme for the advancement of expertise as established by the NIAZ for auditors and works on evaluations, both of the audit team and well as the individual auditor.

4. Independence of auditor

4.1. The auditor who is involved in an accreditation programme for a health care organisation may not have been involved in the activities of the organisation during the previous two years.

4.2. The auditor who is asked by the NIAZ to participate in an accreditation programme at a specific organisation, shall – should it be applicable – on the occasion of this request on his/her own accord, notify the NIAZ that he/she has worked for this organisation in the past and in which position, regardless of the period of time which has since lapsed.

4.3. Until the decision has been taken by the NIAZ about the accreditation status of the organisation, the auditor shall not undertake any activities, in any circumstances whatsoever, in this organisation during this period, and also not promise to accept to undertake such activities at this organisation after this period of time has lapsed.

5. Obligation of confidentiality auditor

5.1. The auditor will treat all that he learns as an auditor with confidentiality. This obligation of confidentiality concerns information which is not legally accessible for the public or third parties and which he/she should understand to be confidential, in relation to the NIAZ itself and the organisations and persons with whom the NIAZ maintains relations.

5.2. The auditor ensures that documents which are or will be at his/her disposal, in writing, digital or any other form, cannot be viewed by third parties. The auditor ensures that these documents are adequately destroyed or submits them to the secretarial office of the NIAZ for them to be destroyed.

5.3. The auditor will not make use of this information for purposes on account of another function/position other than that in the NIAZ.

5.4. The obligations of confidentiality remain in existence after an accreditation programme or the other working activities as referred to in this regulation have finished and likewise once the auditorship has ended.

6. Compensation

6.1. The auditor has the right to compensation for the working activities, in the case and to the extent that these have been stated as subject to compensation by the executive board or management. Should the auditor be an entrepreneur liable to VAT, then VAT can be charged above this amount, providing the provisions for that purpose are met (amongst other things: dated and numbered invoice which states the VAT number).

6.2. The auditor provides a specified declaration or invoice. He/She indicates to whom the compensation should be payable.

6.3. In the compensation to be paid to the auditor or other beneficiary all the payments due for the purpose of fiscal legislation and social insurance should be considered to be included. The auditor or other beneficiary should themselves take care that an adequate declaration of the compensation is submitted to the tax authorities as well as the payment to the tax authorities for the purpose of the payments due. The auditor safeguards the NIAZ against all claims from the treasury or the executor of the social insurance.

7. Liability

7.1. The NIAZ stipulates that it is excluded from liability at the organisation for any possible damage which occurs during the accreditation process, unless deliberate or gross negligence can be said to exist on the part of one or more persons engaged there by the NIAZ.

7.2. NIAZ safeguards the auditor against liability on the same basis as stated in the previous paragraph.

8. Adjusting and changing regulation

8.1. Regarding cases not provided for by this regulation, the decision rests with the NIAZ Board. For an individual case with significant reasons, in the interests of the NIAZ and in accordance with the values of the NIAZ and its contractual obligations towards third parties, the NIAZ Board may deviate from provisions in this regulation.

8.2. At all times, this regulation may be adjusted by the NIAZ Board and it will then apply to the auditor in its adjusted form.

8.3. The NIAZ informs all the auditors in its pool about every change in this regulation.

Established by the NIAZ Board
dated 26 November 2008