When a center is eligible for audit for the next audit year1, the CIBMTR will send a notice of the upcoming audit to the center and start the process of scheduling the audit in mid to late spring. The transplant center’s primary contact and Medical Director will be notified of the upcoming audit and asked to finalize the dates of the audit.
Audits are most commonly performed over 4 days (Monday – Thursday). Audits typically include two auditors; however, additional auditors may be present if a Cellular Therapy Audit is also occurring, due to training, etc. The audit may be performed onsite or via remote access to the electronic medical record (EMR).
Twelve weeks prior to the audit, an email will be sent with general audit and auditor information. This email will also include a link to a pre-audit questionnaire. The primary contact should complete and return the pre-audit questionnaire.
Eight weeks prior to the audit, recipients will be selected for audit. All forms in complete status for each recipient selected for audit will be locked at this time. The lead auditor will provide the site’s primary contact with a list of the 16 transplant events that have been selected for audit. A list of eight cellular therapy events will be included if a Cellular Therapy Audit is also being performed. As a reminder, the auditors will need full read-only access to the EMR to complete the audit. As this process can sometimes be lengthy, any required consents / documents for medical record access should be sent directly to the auditors as soon as possible to avoid any issues with conducting the audit. At this time, the first of two pre-audits will be scheduled. In the first call, EMR access will be discussed along with any documentation that needs to be completed to grant access. In addition, an overview of the audit process will be provided along with a summary of the audit week and any required meeting times for the opening meeting, daily check-ins, prior corrective action plan review and the closing meeting. There will also be an opportunity to have any questions regarding the audit week answered.
Approximately four weeks prior to the audit, during the second pre-audit call, EMR access will be confirmed, and the schedule of the audit week will be finalized. An audit agenda will then be created and sent to the center following the call, along with invites for each meeting. See Meeting Time Requirements for additional information.
1 The audit year corresponds to the fiscal year (October 1 – September 30).