The corrective active plan listed by Richard Counts is very complete. I went thru the exercise myself, formatting the response with the corrective action plan included, described below:
Cover Letter that includes:
• Date the response is submitted
• Thanks to the audit team for the findings with summary of the finding/s
• Organization performing the audit, purpose of the audit, names of audit team, date of the audit, date the audit report was submitted
• Notation on the form of the response (2 hard copy, one CD)
• Description of the response team
• One contact name, phone, and email for the audit team to directs questions they may have on the response
Corrective Action Plan for Each Finding
• Specific finding and department
o Any additional information audit team requested and date requested
o Any additional information provided to the audit team and the date it was provided
o Any questions the response team had on the documentation of the finding and the date of the question
o Any clarification of the finding by the audit team and the date of the clarification
• Actions/circumstances that contributed to the finding
• Steps, dates and proof of corrective action (restitution), if required
• Procedure / policy changes for compliance
• Date of implementation of procedure / policy changes
• Monitoring system to insure continued compliance
• Department and personnel responsible for monitoring
• Documentation of dated report data meeting compliance
Appendixes
• Updated Policy Manuals
• Data Tables
• Etc.
Excellent details - thanks for contributing!
Richard and Maureen have done an excellent job of outlining the Corrective Action Plan. I think that such checklists are very helpful. Additionally, to digress a little bit, I think that the documentation should be readily accessible and codified in the institution so that if/when there is turnover, new administrators can without too much grief and minimal training/ mentoring step up to the plate and take over.
Great point, Monica. Turnover can have a significant impact on an organization. Clear documentation on policies and procedures is critical to employee transitions. I've often heard that audit findings are tied to new employees/high turnover/lack of training, etc.
While we all seem to be agreeing that Richard has a reasonably comprehensive list, I have found that continuing oversight is required. With employee turnover, there is somtimes an incorrect assumption (or presumption) that the corrective action plan is 'still' being implemented.
key control(what area is being tested)
what the worksheet that you are completing (area of audit)
the result of the audit
the action plan to take
who the champion wil be
the progress of the plan (complete, submitted, etc.
targeted date completed
approved by the steering committee
actual completion date
Good list, Julie. What mechanisms do you use for tracking if the item is not completed by the target date?
Wow, great list. I am on my way to make sure we utilize it at our school.
All teams should fill out checklist, before picking up pay checks!
I think that the list includes some great topics. An effective root cause analysis should be conducted on each item identified. Documentation should be thorough and clear about action plans to remedy the irregular circumstance. The audit team should conduct a second audit to ensure that the proper corrective action took place.
Well, with this list already here, what is there to add? This is great and very comprehensive.
The only thing I'd like to say in addition, is that on my campus what we have found to be an effective tool in making corrective action plans happen, is for each department to understand fully their function, and how a mistake make by their department, even if it seems small, can cause a larger more difficult to correct problem for another. This type of cross-education allows each person to understand their job better and therefore correct mistakes they have been making previously.
You need the include the finding. You need to explain how you are going to avoid future finding. This includes the action plans and the steps that are going to be taken to avoid this. I would also include if you have corrected the findings (if it can be done).
The plan should include the findings first and the corrective approach the management team plans to take.
Excellent feedback, Courtenay. Oftentimes, people don't see the importance of something they do and it can "fall off" of their task list as a result. Understanding the WHY behind processes, including impact on other departments, helps reinforce the importance.
I do think it is important to make all departments aware of resolutions and action plans.
I concur with Richard's list. I would also emphasize "white paper" or evidence based documentation. Some type of plan or template demonstrating corrective action. Of course, this depends upon the violation/recommendation however, EVIDENCE is critical to this process.
If there was an admissions department audit, and there were non-compliant findings with respect to marketing materials, a corrective action plan must include the submission of new marketing materials (ie. print ads, flyers, direct mail packages etc.)proposed for future use that demonstrate compliance.
Great lists - It is important that the staff become involved with the corrective action plans and understand the importance to the company of compliance and follow through. Monitoring proof of correction and post audit testing is important. The use of audit spreadsheets is helpful and criteria reviewed on a regular basis.
Yes, Catherine. the validation of correction is critical and all employees need to have compliance as part of their responsibilities as it hits all departments.
I totally agree with Courtenay. Each Dept. Manager should fully understand their function as we'll as other dept functions. As a Shool Owner, we sometimes feel that if we want to accomplish something we shoud do it ourselves. Thats okay when you first start your school, but after years and hundreds of students, delegating and proper function education for the staff is a must.
