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
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.
For the sake of being redundant I will have to agree with Richards and all the items he has listed.
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!
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,
What a great list! Well done!
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's list is perfect! I wouldn't change it a bit!! Document, Document, Document!!!
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.
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!!
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.
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.
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!
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.
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.
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.
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.
Great list, I feel using this list will help our institution tremendously.
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.
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.
