What I have learned from my findings is that you have to act immediately.
A new policy or a rule has to be implemented in order to make sure that will never happen again.
The response to any finding should address PPF (Past, Present and Future). In other words, you should explain what happened, what the consequences were, what you have done to correct it and therefore is now compliant and what implementations have taken place to insure it does not occur again.
I agree-great list. Perhaps you could also add who generated the audit findings, i.e. who conducted the audit and who was on the audit team as well as a definition of the scope/purpose of the audit so that any findings can be put into context by persons who might be reviewing audit reports in the future. The audit report and relate responses are documentation themselevs that should define the scope of the audit for future reference.This may have been implicit in the list, but it ws so thorough I couldn't think of anything else to add!
I agree with many of the comments. A corrective action plan should have the standard in which the department is non-complaint as a start off point. Additionally, the specific findings should be listed and suggestions for improvement and a time frame for correction. It's almost like a personnel action plan. You want the expectations to be clear and precise and a timeline for rectification.
A correction action plan should include each area in which the department was found non-comliant along with a specific remedy for each problem found. It should also show proof that the problem area has been fixed or a time line of when it will be fixed, in the event that it is something that cannot be fixed immediately.
Excellent point, Shannon. You are right - the focus can be so much on response to the audit team versus the individuals responsible for implementing the action plans. This is a good point to keep in mind!!
I do think it is important to make all departments aware of resolutions and action plans. I think many of us forget to do this crucial step.
Richard's list is perfect! I wouldn't change it a bit!! Document, Document, Document!!!
Documentation is extremely important. Date of the audit, concise record of all findings, including personel involved need to be documented. A report needs to be written, a solution suggested and a file created.
Richard,
What a great list! Well done!
I would want to see the following:
a) An explanation showing an understanding of the finding; i.e. what might have caused it.
b) Proof of correction, if applicable
c) Explanation of changes being incorporated to prevent similar future findings.
Signed & dated.
Richard's list is pretty comprehensive. Make sure you give the auditors the answers they want or your issues will NOT be considered resolved. Remember to provide thorough written documentation in your response. Think in layers!
For the sake of being redundant I will have to agree with Richards and all the items he has listed.
A corrective action plan should include two types of material:
1. A detailed description of the audit finding.
2. A detailed action plan outlining what caused the item(s) to be out of compliance and what must be done to fix the non-compliance. This section should be specific, action-oriented, measurable and time specific so that the next audit can clearly document what was done against the corrective action plan and whether or not the actions worked.
I think that the following should be included in a corrective action plan in response to an audit finding.
The Auditor (name/company)
The finding
Date of the finding
Responsible party
Detailed information on correcting the finding
Estimated time frame for follow up
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.
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.
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
Good checklist, Daniel. I think number 7 is the key to ensure that the plan is "working".
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
