建立以病人為焦點的內部稽核追索計畫及內部稽核人員認證制度：以區域醫院四年經驗為例

Establishing a Patient-focused Internal Audit Tracer Plan and Internal Auditor Certification System: Taking the Four-year Experience in a Regional Hospital as an Example

臺灣醫院於追索查證方法實務運作發表較少，且尚未有內部稽核人員培訓認證制度文獻發表。專案醫院製作28項以病人為焦點的內部稽核追索計畫包含：1.流程追索圖；2.內部稽核查核表；3.流程相關作業標準書清單；4.流程相關指標清單，以驗證作業程序是否符合醫院內外部規範。文中以中央廚房食品安全/供膳管理/營養照護流程之內部稽核追索計畫為範例做說明。2018年至2021年透過專案設計之內部稽核人員培訓認證制度授予主稽核員及稽核員共76人證書，合計辦理15場課室教學及2場內部稽核實務示範，滿意度均在92分以上。本文以跨專業的合作模式設計追索計畫，建立培育稽核人員分級認證制度之寶貴經驗，提供各醫院準備各式評鑑常規執行醫院內部稽核參考。

In Taiwan, there have been few publications on the practical operation of patient focused methods in hospitals, and no literature has been published on internal auditor training and certification systems. A study hospital developed 28 patient- focused internal audit trace plans, including (1) process tracer maps, (2) internal audit checklists, (3) process-related operating standards lists, and (4) process-related indicator lists, to verify whether the operational procedures comply with internal and external hospital regulations. The article uses the internal audit trace plan for food safety, meal provision management, and nutritional care processes in a central kitchen as an example. From 2018 to 2021, through the implementation of a project-based internal auditor training and certification system, a total of 76 certificates were awarded to lead auditors and auditors. This included 15 classroom-based teaching sessions and 2 internal audit practical demonstrations, with satisfaction ratings above 92 points. This article designs a traceability plan using an interprofessional collaboration model, establishing valuable experience in creating a tiered certification system for training auditors. It provides a reference for hospitals in preparing for various types of hospital accreditations and the routine execution of internal audits.