Internal Audit for Business Continuity Management System Focused on Procedure Manuals in Hospitals

Abstract

Japan is one of the most natural disaster-prone countries in the world. During a natural disaster or mass casualty incident, hospitals are likely to receive a large number of injured people. Some hospitals have established a Business Continuity Management System (BCMS) to increase healthcare resilience. One of the most important activities in a BCMS is an internal audit. This enables auditors to grasp certain problems effectively and efficiently by preparing audit items beforehand. Internal audits in BCMS target activities that take place during a disaster. There are some characteristics of disaster medicine, such as the restriction of physical and personnel resources, which do not exist in routine work. It is important to conduct an internal audit by considering these characteristics to improve the continuity of disaster medicine provision. This study aims to identify these characteristics and clarify the audit items for the BCMS. This study also demonstrates the results of an internal audit by applying the proposed audit items at an acute care hospital. Furthermore, although an internal audit has many possible focus areas, this study discusses audits from the perspective of disaster procedure manuals, which enable us to better grasp the details of disaster medicine.