Corrective Action Plans
Describe what should be included in a corrective action plan submitted by a campus or department in response to audit findings. Include specific topics/items that you would want to see for each finding.
This assignment is complicated due to the diverse types and impacts of possible findings. However, in an attempt to get the ball rolling in this discussion forum I submit the following:
Date Finding Reported
Date Response Submitted
Additional Information Requested in finding(if applicable)
Date Additional Information was provided
Identification of Campus and/or Department Responding
Identification of individual preparing the Response
Statement of Specific Finding for which Response is submitted
Steps required for restitution (if applicable)
Date restitution accomplished (if applicable)
Actions/Circumstances that contributed to finding
Procedure/Policy developed to resolve issue raised in finding
Date of implementation of Corrective Procedure/Policy developed
Monitoring System designed to ensure continued compliance
Department responsible for monitoring activity
Individual(s) with direct responsibility for monitoring activity
Reporting required to demonstrate continued compliance (if applicable)
Target dates for report generation/submission (if applicable)
I think this is a great list. Very thorough. Although there are diverse types and impacts from findings, I think a standard format/list ensures that items are completely addressed. I particularly like the reference to a monitoring system for continued compliance and the possibility of reporting required to demonstrate continued compliance. Too many times, schools focus on the restitution and not preventing the problem from happening again. The other thing that is often overlooked is the root cause. I think it's good that you have a section about what contributed to the finding. Digging for the real cause versus just the sypmtoms is the key to fixing the matter long term.
It should include the acknowledgement of the findings. What might have caused this problem.
The plan to correct this problem and also how to prevent the finding from occuring again. There should be a timeline in place for their plan.
Janie - I agree with the areas you identified for inclusion. I am also a strong advocate of designating a person as the responsible party to execute each item on the plan. Richard gave a very complete list at the beginning of this discussion thread that is worth reviewing and incorporating into plans.
I also will be posting some sample templates for this course soon for reference to all of you in the course that will include a plan template. I am hoping to get responses when those are posted as I would like to continue to update or add to the samples those to reflect recommendations from these forums.
Richard's list is quite comprehensive. These are the same items we are looking for in our responses from out Internal Audits. We also do an Exit Interview with the key players at our schools. I am a firm believer that none of the findings in the audit write-up should be a surprise. When our audit team leaves the school they have essentially told the management team all of the areas of concern or noncompliance.
We encourage a dialogue between the school's management team with regards to responding to the audit findings. We try to ensure that the whole issue is resolved not just one record. Because responding to audits is not everyone's favorite thing to do, we provide an electronic version with an area for the school response provided. It encourages responses to occur on a timely basis.
Ultimately, it comes down to follow-up. If a process is not in place to monitor the area of noncompliance and follow it up, then conducting self audits will become meaningless.
Excellent points, Kathleen. The dialogue and ongoing communication helps to keep the momentum on the resolution. I like the idea of providing an easy means of response with an electronic document.
Not only are self audits meaningless without follow up but, they can create risk for entities who identify problems but, do not resolve them.
A great list. I would like to emphasize the importance of documentation. All areas of support in the corrective action plan should be documented and verifiable – essential to ensure compliance.
Richard's list for a corrective action plan is very helpful. I also see great value in Janie's comment on attempting to determine, and asking the campus itself, what caused this to happen. Awareness is truly the only way to prevent a reoccurrence. Do you think it would work to include this discussion in the exit interview or should it be done prior to the exit interview?
Lori,
I am glad that I may have contributed in some small way to assisting you in your efforts to ensure on-going compliance and efficient operations. If the discussion you refer to is intended to address causative circumstances, actions, etc., I think that the timing of that discussion would be dictated by the nature of the finding. Some findings might warrant that discussion taking place during the discovery process, others during the exit interview, and others may need to be researched by the school in order to fully understand what went awry. I generally try to be very forthcoming and thorough during the discovery process and very brief during the exit interview. But I have worked with others who seem to favor a different approach. I am interested to see what others suggest. I hope that I understood the nature of your question correctly. Thank you for letting me know that I may have been helpful to your efforts in some way. As you know, it is having the opportunity to help others that attracts people to and keeps people in this wonderful and challenging profession.
I'm sure there will be varying opinions on this but, I try to keep these discussions out of the exit interview to keep that meeting short and to the point. Ideally, the department with this finding has already been informed, prior to the exit, of the matter. Typically, if they know the "why", they will offer it up immediately. Other times, it requires research. Eventually, the root cause should be identified in their formal written response, but, I agree that if the discussion can happen in the field, it encourages open communication between the team and the campus. Additionally, it helps the audit team evaluate the potential risk as it relates to whether or not the problem is likely to be occurring at multiple sites or if it seems to be more of an isolated occurrence.
The plan should include accountable parties, timelines and guidelines along with an approved action plan for each finding.
Audits are stressful, no matter if they are conducted by an internal or external party. It is uncomfortable as a manager to feel as though your work is being judged by someone who does not fully understand the challenges you face-constant interruptions, not enough hours in the day, etc.
When an auditor tries to understand why something occurred, it often comes accross as trying to assess blame. That will generally trigger a defensive response, which does not serve the internal audit process well.
Whenever possible, I think it is better to receive and review the action plan, partner with the manager to suggest best practices or alternatives, if needed, monitor implementation of the plan and then do a follow-up visit. In the course of the process the "why" will come to light.
Cheryl,
This is a valid point but I think there is great value in the recipient of the finding performing research to identify shortcomings in procedures, processes, or staffing. It is not for the auditor's benefit that the reason for the shortcoming is requested. It is to ensure that the department or manager involved give serious consideration to legitimate factors that contributed to the finding and develop a plan to impact those factors. I have found that the sharing of "best practices" not first identified by the respondents are equally likely to be received with a "they don't understand the challenges I face," attitude. Becoming "defensive" and/or looking to assign blame are entirely counterproductive responses to audit findings or other forms of constructive criticism. Audits should be conducted for the purpose of uncovering areas in which performance can be improved and identifying areas of exemplary performance. Allowing the respondent time to seriously consider contributing factors often also allows time for the defensive reaction to subside and productive consideration to take place. At least this is my experience.
I completely understand the concern about defensive reactions - I agree with Richard that working directly with the respondent to determine root causes can be beneficial. In some cases, I have actually seen this make people LESS defensive as they have the opportunity to help find the root cause instead of feeling like they are being accused behind their back to their supervisor during "private" meetings.
I tend to lean toward the "transparency" approach whereby keeping communications open, as much as possible, brings a greater element of trust and understanding in the positive goals of an audit process.
Regardless, the stress of an audit can always cause some defensiveness from respondents and auditors are always challenged to develop a positive rapport throughout the process to assist in creating a cooperative culture to reduce the "we/they" syndrome which can easily occur when individuals know they are being reviewed.
In a corrective action plan I need to included the action taken to resolve the situations and avoid to
repeat. Including the apropriate time for corecting.
Richard, I think your list, as the others have stated, is comprehensive and very nicely done.
I would add that it should be formulated by someone at the top of the pyramid who is capable of making sure that the corrective action plan actually stays in place. Otherwise, things will revert back to the pre-audit status.
Very true, Howard. Support from the highest levels is critical to ensure that any changes "stick".
Yes, Jorge. No time limit, no action plan.
