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Resources: For Accreditation - Evaluation Instrument

Evaluation Instrument for Accreditation

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Latest Update: May 15, 2022

Table of Contents

INTRODUCTION DOMAIN I: ORGANIZATION DOMAIN II: INSTITUTIONAL REVIEW BOARD OR ETHICS COMMITTEE DOMAIN III: RESEARCHER AND RESEARCH STAFF TABLES

ELEMENT I.5.A.

ELEMENT I.5.A.: The organization conducts audits or surveys or uses other methods to assess compliance with organizational policies and procedures and applicable laws, regulations, codes, and guidance. The organization makes improvements to increase compliance, when necessary.
An organization’s quality improvement program should include measures of compliance with organizational policies and procedures and applicable laws, regulations, codes, and guidance. 

The organization’s quality improvement program should include an evaluation of the HRPP to determine whether it is effective in achieving compliance.

The organization should collect objective data through audits, surveys, or other methods and use the data to make improvements and monitor compliance on an ongoing basis.

The number of audits or surveys, or the breadth of the audits or surveys, conducted should be determined by the organization and sufficiently robust to provide data that inform the quality improvement program.

Regulatory and guidance references

  • None

Required written materials

  1. Essential requirements:
    1. The organization has a quality improvement plan that periodically assesses compliance of the HRPP.
      1. The plan states the goal of the quality improvement plan with respect to achieving and maintaining compliance.
      2. The plan defines at least one objective to achieve or maintain compliance.
      3. The plan defines at least one measure of compliance.
      4. The plan describes the methods to assess compliance and make improvements.

     


    Common types of materials that may be used to meet the element

    • Compliance plans
    • Audits, surveys, or data collection tools
    • Surveys
    • Evaluation reports

    Outcomes

    • The organization monitors compliance based on objective data and makes improvements, when necessary. 

    Proceed To: ELEMENT I.5.B.