Governance & Integrity
Management review that drives continual improvement
A management review structure that turns data into action.
Why this matters
Credible accreditation depends on consistent methods, clear decisions, and evidence that stands up to independent review. This publication translates essential expectations into practical steps so teams can prepare, communicate, and operate with confidence.
Key requirements and expectations
- Separate evaluation from decision to protect impartiality.
- Document roles, responsibilities, and oversight mechanisms.
- Use risk-based controls to prevent bias or errors.
- Record evidence of review, approval, and follow-up.
- Inputs should include complaints, PT results, and audit findings.
- Outputs must assign actions and owners.
- Review cadence should match operational risk.
Evidence and records to prepare
- Policies and committee terms of reference.
- Minutes from governance or impartiality meetings.
- Risk registers and mitigation actions.
- Corrective action records when issues are found.
- Management review minutes with action tracking.
Common pitfalls to avoid
- Undocumented decision-making or informal approvals.
- Conflicts not disclosed or not managed to completion.
- Governance roles that are unclear or overlapping.
- Lack of evidence that actions were implemented.
- Holding reviews without documenting decisions or actions.
Practical checklist
- Confirm governance roles and independence boundaries.
- Document conflict disclosure and recusal steps.
- Maintain an auditable decision trail.
- Verify corrective actions are closed effectively.
- Track management review actions to completion.