[UNE-EN-ISO-9001 internal audit program performed by our own personnel: a knowledge management tool]

The need to maintain a Quality Management System based on the UNE-EN-ISO 9001:2000 standards in 12 Departments of the "Hospital General Universitario Gregorio Marañón" (HGUGM), led us to make the decision to establish an internal audit program using our own personnel as a useful tool for knowledge management and continuous improvement. The Department of "Medicina Preventiva y Gestión de Calidad" developed an Audit Program, which has been implemented in our Hospital during the last three years.

We conducted a training program for internal auditors, who then became part of the hospital audit staff. Quality Managers of the accredited departments were consolidated as a group. A procedure for scheduling and coordination of audits was developed. The auditors and those audited were surveyed on the difficulties in conducting audits, including a section for suggestions, and an annual report was drafted with the results of internal and external audits, as well as the improvement areas identified in the whole process.

A total of 40 internal audits have been performed in HGUGM since 2007, and 38 people were trained. The Quality Management System improved in terms of the decreasing number of non-conformances (NC) in external audits, and all services have maintained the certification.

The perception of auditors and those audited regarding the performing of internal audits by our own personnel is very positive. There were identified improvement areas and common solutions.