Building an auditing and monitoring process does not mean we need to start from scratch; however standardizing the process can be a challenging task.
Because of our unique place in healthcare and the services we provide, we usually have both internal and external audits. What’s the difference?
An internal audit is conducted by an internal department (e.g. Facility audits) and the results and resolutions are reported internally. Similarly, an external audit is conducted by an external entity. These entities could be a private audit firm or state, federal or other reporting agency and the results and resolutions are reported both internally and externally.
Our internal audit is our first line of defense when it comes to identifying system problems and operational gaps. When we identify potential non-compliance it is important that we address those gaps immediately where possible or develop a corrective action plan to outline how we plan to fix and resolve any non-compliance.
Consider the following:
- Let your risk areas drive auditing and monitoring
- Use existing results from both internal ande external audits
- Keep business unit stakeholders heavily involved in the process
- Reinforce corporate compliance program objectives
- Don’t be overcome by the documentation process
Pre-Audit – Ensure that the appropriate subject matter expert (SME) is involved in the planning, implementation and resolution phases of the audit. Have regular meetings to discuss any challenges as they pertain to gathering audit materials. Always do quality controls check on the data that will be audited prior to starting the audit.
During the Audit – Manage scope creep, always try to provide only the materials that are needed for the audit. Answer questions that are specific to the audit and always make sure SMEs are available to auditors during the audit.
Post-Audit – Review and report findings. Draft an action plan to address non-compliance. Confirm an implementation and re-evaluation timeline. Review lessons learned to improve future audit process.
