I do think it is important to make all departments aware of resolutions and action plans.
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.
The plan should include the findings first and the corrective approach the management team plans to take.
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).
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.
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.
All teams should fill out checklist, before picking up pay checks!
Wow, great list. I am on my way to make sure we utilize it at our school.
Good list, Julie. What mechanisms do you use for tracking if the item is not completed by the target date?
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
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.
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.
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.
Excellent details - thanks for contributing!
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.
If an auditor finds something wrong and knows why it occurred and how it can be corrected, I, as the owner of a career school, would be very grateful for that information. Is there a regulation against auditors providing this information? Is it common for schools to receive multiple findings? I am extremely distressed over one finding.
Does Richard need a job? Very well put together list. I would have to say that the most imporatnt part is that you are instituting what you are saying that you are. Anyone can submit a corrective plan but a compliant institution needs to follow it.
Great list, I feel using this list will help our institution tremendously.
Anna - Good point. I have seen many good "action plans" which have not been implemented. The action, and validation that is has the intended impact, are critical to success.
I agree that a corrective action plan should include specific list items to be addressed in addition to the implementation of a monitoring system to insure that the problem does not reoccur. A thorough response should include the nature/root cause, steps to be taken to implement corrective measures and possibly proof of corrective action applied.
