When we issue an audit report, the corrective action plan should include:
1. Detailed action plan as to how the finding is being remediated. This must be specific.
2. Action item owner
3. Action due date
Once we have received the responses, we evaluate the corrective action plan. If we don't agree with the plan or it lacks detail, we request more information. We also perform follow up testing on all action plans to ensure they were implemented.
Thanks for sharing, Dale. I have had a few questions lately about how internal audit departments support ongoing audits while also doing the follow up on action plans from completed audits. Do you have any suggestions or guidance you can provide regarding how you balance those responsibilities?
Color coding is an option that internal audit departments could use to track ongoing audits and their status vs. completed audits.
Our school is very small but I was still able to put in action the great information that Richard provided by creating an electronic form that uses color coding. I have my findings listed in red and actions are in blue; once all deficiencies are complete the final notes are green, good to go.
Color coding is an option that internal audit departments could use to track ongoing audits and their status vs. completed audits.
Our school is very small but I was still able to put in action the great information that Richard provided by creating an electronic form that uses color coding. I have my findings listed in red and actions are in blue; once all deficiencies are complete the final notes are green, good to go.
That's a great way to highlight what is outstanding vs. completed. Thanks for the valuable suggestion, Elizabeth.
Documentation, documentation, documentation! I 100% agree with you John. Proper and accurate documention saves you (nearly) everytime! If you can justify an auditor's question / issue with accurate documention they're more likely to dismiss their question and move forward with the audit process.
I am not sure how to comment on this topic. I am very new to the schooling business and everything that comes with it.
What ever they ask for. Lots and lots of paperwork and this is very time consuming. Something no one wants to go through.
While there is inevitably paperwork involved, I think there are good practices in place today that focus on processes validation and some electronic tracking. This should reduce the volume of paperwork and keep the audit at a meaningful level that can be easily referenced for follow up without cumbersome, unnecessary volume of information and paper.
Documentation has become one of the most important tools at our school. With the number of different students and the number of different situations that have been come about, it is impossible to think back and remember how things were resolved for every student. Documenting also provides a link between separate departments that may also help during the audit process. One department may have information that the other doesn't. Documenting allows for all departments to be in sync with each other which shows a sense of organization on campus.
I completely concur - and would add that it is critical that the documentation be tied to a student's record (either hard copy or, ideally electonically) to ensure that it is not just in an employee's drawer or a Word document on an employee's computer. The reality is that, as a school grows, there is no easy way to recall and track down a document unless it is linked direclty to the relevant student's record.
I found Richard's list very helpful, as I am new to this industry and to the audit process. It was good to be reminded about the importance of documentation and of ongoing communication to keep the momentum going. I like the idea of tying the documentation to the student's record. And I look forward to seeing the sample templates that will be posted.
We are currently in the process of responding to an external audit. I have been asked to develop a plan for an internal, ongoing audit to better prepare us for our audit next year. So this discussion has been quite helpful. Thanks!
The corrective action plan needs to re-state the finding and then should state the steps put in place by the department to correct the finding. I have found that when responding to an audit, everything needs to be neatly put together even going as far as having it professionally bound (say by Kinkos). The detail of the documentation to show corrective action for each item cited must be extensive. The way you handle the response will show the auditors how seriously you take their findings and your determination to improve.
I think that a corrective action plan should be WELL DOCUMENTED in all areas. Submit, in detail, each and every step being taken to resolve the issue. Explain why the steps have been chosen. In my opinion, the more explination you have, the more understanding those utilizing the plan will have.
I agree with you Bonnie, that thorough documentation is important. I also think it's important that the corrective action plan be reasonable for ongoing maintenance - in other words, should meet the needs to correct the problem but, not be "overkill" creating unproductive busy work. I have seen some schools "over commit", creating administrative complexities that did not contribute to the overall quality/improvement of the initial finding.
Corrective Action Plan within a department:
1. The Findings (ID issue of non-compliance)
2. Date of the Finding
3. The "finder" or auditor
4. Identify what is needed to "correct" the
finding, if possible
5. Identify the party responsible for
"correcting" the finding
6. Create a deadline for correction of the
finding(s)
7. Meet to determine that the findings have been
corrected or need further action
Good checklist, Daniel. I think number 7 is the key to ensure that the plan is "working".
The items in a corrective action plan should depend on the finding. The common elements should be:
* date of the visit/audit
* date of the finding
* name of the student, faculty member, or whoever is relevant to the citation
* circumstances that led to the citation
* either a response that the finding was inaccurate or proof that the issue has been resolved
* documented policies or processes that will prevent the issue from occurring again
* name of the respondent
* contact information for the respondent
* citation number, if applicable
You bring up an interesting topic that I don't think has come up on this discussion thread - inaccurate findings. Ideally, if the item is raised during the audit, the school can provide proof that the finding is not valid so it never makes the report. But, if it is in the report, the response indicating the inaccuracy should also provide evidence of the invalidity of the finding. And, as you point out, it's also ideal to demonstrate that resolution is already in place for valid findings and well as the guidelines you noted for prevention from repeat problems. Good job with this list.
I also agree that Richard's list is comprehensive. I would use this as a template for responding to audits. In addition, I think the campus team ( the managers of the campus ) should all be involved the the resloution of audit findings to ensue that all departments are aware of the findings and to work together to resolve the issues. Audit findings in one department does not relieve the other departments from responsisiblity. If the campus managers work as a true team, they should accept findings as a team.
