Table 2.

Themes, categories and quotes relating to effectiveness of internal audit

Theme	Category	Quotes
Use of the internal audit for identification of safety risks	Broad, multidisciplinary scope	‘Well, an internal audit is department-wide and multidisciplinary, you talk with professionals of that department, but also with its customers. Like, if there’s an audit at radiology, you talk to specialists of other departments that use the services of radiology as well. With tracers, you don’t have that complete overview.’ ‘And the internal audit contributes to an overall view of a department, of a group of people who are active within a certain discipline: clinicians, nurses, allied healthcare professionals… and yes, you get insight into the department on an aggregated level.’
	Soft signals	‘[With the internal audit] you can get a global impression regarding the actual performance, so to say, and cooperation as well (…). The question could be: ‘how is everything going,’ and they would say: ‘perfect, we are doing the best we can’. Well, show me!’ ‘Well, I think that the soft signals… Partially they derive from the internal audit (…) but it is just very complicated, you know. I think an internal audit should begin with the question: ‘Why do you like working here?’ That is not something you can write down in three sentences in the audit report. It is as soft as you can get, but it is very significant for how people are feeling in their job.’
	In-depth approach	‘So it shows where the need for improvements lie and what you should prioritize… It prioritizes in the way, like, what is going right and what is going wrong?’ ‘Especially when auditors don’t just score, but ask questions, you get more information, like ‘why is it going wrong?’” ‘Maybe it’s even more important to be open and susceptible to signals from within the organization. We talk to chairmen of staff and divisions very often. You cannot wait for the internal audit to take place in a few years to feel safe regarding the functioning of a department.’
Use of audit information to steer patient safety	Monitoring	‘And in our quarterly report, in our four-times-a-year cycle, we ask every unit to report on the audits that have been performed; what were the results, what did you encounter and which actions did you think of, and these actions, are they implemented and are they leading towards results (…).” ‘For us, as board of directors, it’s about knowing what the conclusion regarding the department is, in the context of general functioning, leadership and yes, quality and safety. And that is one of the sources we need to, so to say, feel secure in how the organization is doing.’
	Incentive for change	‘Something in which we intervened immediately was the double check on medication. That was a moment in which we said: this is unacceptable. These answers are unacceptable. So I went there, and the medical directors as well, and we said, this is out of the question. This has to change by tomorrow.’ ‘We’ve also looked at what is the reason that that happens; don’t we need to alter the procedure? So it is about steering, saying: ‘this is unacceptable’, but it is also a moment of thinking: ‘did we organize it correctly?’”
Use of audit information to account for patient safety	Use of internal audit information in regular meetings with the board of supervisors	‘Yes, to inform. By the way, our board of supervisors is very on top of it, they will ask: what did you do about it? So you need to have that answer as well.’
	Use of audit information to inform the board of supervisors regarding critical incidents	‘And if we say: ‘This is critical, these people have to be informed before the report is finished’, then I will call them and they will come over.’ ‘It’s not good for internal monitoring because that will cause a mix-up between the responsibilities of the board of directors and the board of supervisors. Negative results of an audit should be solved in the management line of the hospital. Having said that, the existence of an internal audit system, that they are performed accurately, that there are reports on the results and the system as a whole, helps us to trust the board of directors.’