Jane - One of the things to consider with the sample files is how the auditor(s) select the records for the sample. Depending on the purpose and scope of the audit, there may be a "targeted" sample whereby the auditor has already identified a potential problem and wants to dig deeper. Or, it can be a random sample for a general type of audit.
I agree that one should always be prepared for an aduit and work as if the aduitor is doing a visit evey week. I also think one way to prepare is to have peers review each others work.
The first step I would take is looking for the guidelines for the audit/review. What items are required in the meeting room? What do I need to submit prior to the visit/audit? What am I finding as I prepare the items for the visit team? If it is an academic audit, I have all the academic files pulled: active; inactive; graduates; and withdrawn students. I assemble a team that I trust to organize the files in the order of the checksheet. We identify any items that are missing, if applicable, and gather what can be gathered. I look for things that I have seen missing in the past. We double-check all clinical/externship paperwork.
At the same time, I have the Human Resource Director pull all the faculty and staff files. We designate someone to audit the faculty files and look for missing official transcripts, employment paperwork, or evidence of faculty development or the plan itself. Then, the items are prioritized and delegated to someone to gather, if any items are missing.
All the documents for the meeting room need to be prepared in a way that makes everything easy to find for the auditors or visit team. All binders need to be clearly labeled. Files need to be organized consistently. Items that everyone on the visit team will need should be copied and placed at each seat. A computer person needs to be on hand to help with laptop issues or printing needs the day(s) of the visit.
The other steps depend on the type of the visit and the needs.
The only way to be prepared for a known audit, or any audit, is to be in compliance every day. If you are compliant daily, then preparation for an upcoming audit and the audit itself will go much more smoothly.
Kristina - I completely agree that the key to compliance is making sure your daily operations support compliance. I also think that it's important to prepare for the actual audit (when they are known in advance) by ensuring materials needed by the visiting team are easily accessible and organized and that individuals responsible for information during the audit are informed and block their time accordingly.
In an ideal world Compliance should be a major part of the day to day operations. School policies and accreditation standards should be followed at all times. If this is truly the case then, preparation will be minimal. On the contrary, from my experience, circumstances can position you in uncompromising situation at times which may go against policy or accreditation standards. With that being said, it is imperative to maintain appropriate, detailed and organized documentation to show a pattern of compliance. I would ensure the documentation would be available for review and I would guarantee that the appropriate staff would be available to answer any questions the auditing team may have.
DeMario - I like your comment about a "pattern of compliance". It's that consistency that can make a difference - even if there were problems before a certain time, a pattern of compliance since that point can be helpful and convincing to auditors. Staff availability is also critical - having done audits, nothing is worse than not being able to get questions answered if the "person who knows" is unavailable.
We were recently reviewed by acics, and worked to prepare for that visit. We decided that our four schools would work toward 100% compliance everyday. We send regional staff members out to campuses to randomly review files in each dept.....and try to coordinate this effort.
Linda - I like the idea of 100% compliance everyday. It makes for much easier preparation when there is a regulatory visit.
This is also my philosophy. Having created the internal audit procedures, I was careful to always approach issues with a non-accusatory approach. If the employees perceive you as being on their side, helping them to do the best job they can, everyone wins. The point is to resolve non-compliance, not to get people in trouble...
Barbara - I completely agree. The challenge is sometimes HOW to present findings without coming across in an accusatory manner. Do you have a strategy for how to present findings to come across in your positive manner?
Great tip. Thanks, Kathleen.
Organization is the key. I would give thought ahead of time about what the autitors would be looking for and be prepared. I would make sure that all of my files were in order and that I knew where everything was.
Compliance every day is the key. Make unannounced "mini audits" by managers in each functional department. This keeps everyone's mind on compliance at all times!
I agree with Bonnie. Preparation for an audit should never begin when you get notified that you will be audited--it's something that every member of every department needs to be striving for in their daily work.
We use a dedicated team comprised of staff and faculty from a variety of disciplines for our audit team.
Shannon - two really important points in your comment: First, the dedicated team makes for emhpasizing this priority. Second, the variety of disciplines represented helps cover the vast areas that must be audited.
I would meet with all department managers and come up with a plan of what each department needs to review to make sure that we are being compliant in all areas. This way we would be prepared for the internal audit and we would hopefully have minimal findings, if any, in each department.
In preparing to be audited, I would do my best to ascertain the scope of the audit, then I would essentially perform my own "audit" of sorts prior to being audited in an effort to address issues that could be addressed proactively and to organize and prime staff for the actual audit. Generally, this is work that would/should be integrated into the regular function of any department that could be the subject of an audit anyway as part of normal business operations.
Crhistine - Looking at your items from the eyes of an auditor is a great approach. What would you do if you find something unacceptable prior to the audit?
