Key Takeaway
MOH audits are coming. They'll check your technical controls, policies, staff knowledge, and documentation. This guide gives you a timeline-based preparation plan—from 12 months out to audit day. The goal: make audits validation events, not stressful crises.
Why MOH Might Audit You
Good to Know
Audit triggers:
Routine compliance monitoring (random selection)
Following a reported incident or breach
License renewal processes
Patient complaints or concerns
Industry-wide sweeps
Bottom line: Any clinic can be audited at any time. Be ready.
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What Auditors Actually Check
| Area | What They Look For |
| Technical controls | Encryption, access controls, monitoring, backups |
| Policies | Written, current, comprehensive |
| Staff knowledge | Can they explain their responsibilities? |
| Documentation | Training records, access logs, incident history |
| Incident response | Can you detect and report within 2 hours? |
Possible Outcomes
| Result | What It Means |
| Compliant | No significant issues—you're good |
| Observations | Minor issues to address (low priority) |
| Findings | Significant gaps requiring remediation plan |
| Non-compliance | Major failures—enforcement action possible |
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The Preparation Timeline
6-12 Months Before (Build Your Foundation)
Think of it Like This
This is like preparing for a board certification—you can't cram the night before. The foundation takes time.
- 1. Internal Assessment
- Inventory all systems containing patient data
- Document current security controls
- Identify gaps against HIB requirements
- Create a remediation roadmap
- 2. Implement Critical Controls
- Endpoint protection on all devices
- Individual user accounts with proper access controls
- Audit logging enabled and retained
- Backup procedures tested
- 3. Document Core Policies
- Data protection policy
- Information security policy
- Incident response plan
- Acceptable use policy
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3-6 Months Before (Strengthen and Train)
- 1. Staff Training
- Security awareness training for all staff
- Policy acknowledgment signatures
- Role-specific training (admin vs. clinical)
- Document training completion
- 2. Technical Hardening
- All systems patched and updated
- Firewall rules reviewed and tightened
- Backup restoration tested successfully
- Encryption verified on patient data
- 3. Documentation Review
- All policies current (reviewed within 12 months)
- Procedures complete and accurate
- Asset inventory up to date
- Vendor agreements include data protection clauses
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1-3 Months Before (Self-Audit)
- 1. Walk Through Your Own Audit
- ] Use MOH checklist (if available) or our [compliance checklist
- Test every control area
- Identify remaining gaps
- Prioritise final remediation
- 2. Gather Evidence
- Training completion records
- System configuration documentation
- Sample audit logs
- Security measure documentation
- 3. Prepare Your Team
- Brief staff on audit process
- Review key policies together
- Practice common interview questions
- Assign roles for audit day
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1-2 Weeks Before (Final Checks)
- 1. Technical Verification
- All systems operational
- Documentation accessible and organised
- Demonstration capabilities ready
- Known issues documented with remediation plans
- 2. Logistics
- Meeting space prepared
- System access arranged for auditors
- Key contacts identified and available
- Schedule confirmed
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Audit Day: What to Expect
Opening Meeting (30-60 minutes)
- They'll cover:
- Introductions
- Audit scope
- Timeline
- Documentation requests
- Questions from you
- Have ready:
- Clinic overview (size, services, patient volume)
- High-level data flow diagram
- Security architecture summary
- Key contacts for different areas
Document Review (2-4 hours)
Pro Tip
Common requests:
Security policies
Training records
Incident logs (if any)
Access control documentation
Vendor agreements
- Best practices:
- Have documentation organised (digital folder or physical binder)
- Explain context—don't just hand over documents silently
- Acknowledge gaps honestly (they'll find them anyway)
- Show remediation plans for known issues
Technical Assessment (1-2 hours)
- They'll check:
- System configurations
- Access control settings
- Encryption implementation
- Logging and monitoring
- Backup systems
- Best practices:
- Have someone technical available
- Be ready to demonstrate controls live
- Explain your rationale for configurations
- Show monitoring dashboards if available
Staff Interviews (30-60 minutes)
Important
Common questions auditors ask staff:
"What would you do if you suspected a data breach?"
"How do you handle patient data access requests?"
"What are your data protection responsibilities?"
"When was your last security training?"
"Who do you report security concerns to?"
- Staff preparation:
- Don't script specific answers (sounds rehearsed)
- Ensure staff know basic procedures
- It's OK to say "I would refer to our documented procedure"
- It's OK to say "I'm not sure, let me check with [name]"
Physical Walkthrough (30 minutes)
- They'll observe:
- Screen positioning (can patients see?)
- Paper record security (locked cabinets?)
- Physical access controls (who can enter sensitive areas?)
- Clean desk practices
- Device security (locked down?)
- Day-before checklist:
- Screens angled away from public areas
- Paper records in locked cabinets
- No passwords visible (sticky notes, whiteboards)
- Desks cleared of patient information
- Screen locks active
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Most Common Findings
Technical Issues
| Finding | What Auditors See |
| Missing patches | Windows 7, outdated software |
| Weak passwords | No complexity, shared accounts |
| No MFA | Single-factor login only |
| Inadequate logging | Can't answer "who accessed what?" |
| Backup failures | Never tested, stored on same network |
Policy Issues
| Finding | What Auditors See |
| Missing policies | Required documents don't exist |
| Outdated policies | "Last reviewed: 2019" |
| Incomplete procedures | Missing critical steps |
| No acknowledgment | Staff never signed policies |
Training Issues
| Finding | What Auditors See |
| No evidence | "We trained them verbally" |
| Outdated | Training from 3 years ago |
| Incomplete coverage | Reception wasn't trained |
| Too generic | Not healthcare-specific |
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After the Audit
If You Pass
Quick Checklist
- Document the successful audit
Thank your team
Continue ongoing monitoring
Schedule next internal review (quarterly recommended)
Don't become complacent
If You Have Findings
- Immediately:
- Review all findings carefully
- Understand severity and required timelines
- Identify who owns each remediation item
- Within 30 days:
- Create formal remediation plan
- Submit to MOH if required
- Allocate budget and resources
- Begin implementation
- Ongoing:
- Track progress against plan
- Provide updates to MOH as required
- Document completion of each item
- Request re-assessment when ready
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The Audit-Ready Culture
Pro Tip
The real goal: Make compliance continuous, not a fire drill.
When compliance is part of daily operations, audits become validation—not crisis management.
Daily Habits
- Document as you go (not "before the audit")
- Keep records current automatically
- Address issues when found (not later)
Quarterly Reviews
- Internal compliance check
- Policy review and updates
- Training refreshers
- System security assessment
Staff Engagement
- Regular security discussions in team meetings
- Reward reporting of concerns
- Share audit results (good and bad)
- Make security everyone's responsibility
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The Bottom Line
Good to Know
MOH audits are not:
Gotcha exercises
Designed to fail you
Impossible to pass
- MOH audits are:
- Verification that you protect patients
- Opportunity to demonstrate good practices
- Motivation to maintain standards
The clinics that struggle are the ones that treat compliance as a one-time project. The clinics that pass easily are the ones where compliance is part of how they operate every day.
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*Not sure if you're audit-ready? Synexo's assessment mirrors what MOH auditors look for. We'll show you exactly where you stand and what to fix. Book your assessment—better to discover gaps now than during an actual audit.*