Is your program required to undergo a program audit or quality site review? If so, it’s likely that just the term “audit ” creates an emotional reaction. Audits can seem like a disruptive annoyance, a “gotcha”, or a procrastinator’s nightmare, but it doesn’t have to be. Like most things, preparation is key. If you and your team are organized, understand the standards, have been keeping good records, and maintain audit readiness throughout the year, your experience may even be positive, and those auditors will be in and out in no time.
The American Society for Quality (ASQ) defines auditing as the on-site verification activity, such as inspection or examination, of a process or quality system, to ensure compliance to requirements. Auditing can also be done virtually or via a desk audit, where items are submitted for review to an auditor. Regardless of how you define auditing, everyone seems to dread an audit. Audits seem to raise a level of anxiety among people even if they believe they are following the “rules”. It does not seem to matter if the audit is internal or from an external entity, no one likes the “gotcha” experience and everyone wants to put their program in the best possible light.
Over the years,I have participated in many program audits. I have also conducted many audits and program reviews. Based on almost 30 years of experience, I have found the following activities not only prepare an organization for an audit but reduce the dread and anxiety that audits produce.
Get organized. Look at a calendar and determine how much prep time you have. Even with very short notice, you can successfully prepare for an audit. Obviously, the amount of time you have will dictate if this is an all-hands-on deck type of preparation or if you have time to thoughtfully divvy up tasks. Review all the information sent to you about what to expect from the audit and what will be required of you. Many times, audit notifications include specific documents that must be gathered, a calendar of activities or topics, individuals to be interviewed, etc. It is also a good idea to review previous audit reports including any corrective action plans that were implemented. Auditors will want to see evidence of those activities and ensure you have sustained improvement in those areas.
Review the standards.Take a good look at what will be reviewed. Standards may be outlined in a manual, in statute, in a contract, on a website, or provided in an auditing tool that will be used by the auditors. It is important to not only review the standards but understand their intent – “The spirit of the law”. By understanding the intent of the standard, you can identify the many areas one standard might involve. For example, a clinical program standard may require a signed consent on file. The intent of that consent is to inform the individual of the risks and benefits of the treatment prior to the provision of services. A signed consent does not meet the standard if it is signed after treatment begins or does not include a description of the risks and benefits of the treatment.
Identify your team.An audit should always be a team effort. It is a great way for staff to learn about the standards and how your organization’s policies and procedures are designed to meet the requirements. It is also a great way for staff to take ownership of their work. Lastly, participating in audit preparation can help individuals understand why certain things are in place. Have you ever had a staff person ask why a certain question is on an assessment or why you must do things a certain way? Most likely it is due to a standard or previous audit finding.
Collect evidence of compliance.Once you are familiar with the standards, begin collecting evidence that supports compliance with each requirement. Evidence may include policies and procedures, training records, clinical documentation, data, etc. Building this physical or electronic “proof box” of documentation is an essential part of being prepared and demonstrating your program’s compliance.
Conduct a gap analysis.Identify which areas you lack evidence of compliance, or areas where your evidence of compliance is not strong. It is always best to anticipate these areas and self-identify standards in advance where auditors may not find evidence of full compliance.
Develop a plan.If there is time, it is always best to attempt to obtain evidence of compliance or steps that are actively being taken towards meeting the standard. There are, however, some items where evidence just does not exist or is lacking. In those cases, the best way to address the lack of full compliance is to develop an improvement plan. An improvement plan can be implemented immediately and will demonstrate to the auditors that you are taking action to correct the issue. You may still be cited, but you will be proactive rather than reactive.
Conduct a mock audit. A mock audit is a great way to assess those areas that are not easily demonstrated through documentation. Mock audits can provide a realistic sense of policies and procedures in action and program staff’s knowledge and understanding of the standards. Mock audits can give you a true sense of what is or is not occurring in the program, offering the opportunity to interview staff, answer questions, and provide feedback.
Create an audit-ready culture.Creating the right culture is probably my most important tip. Coaching your program team to understand the standards, keep documentation up-to-date, and be “audit ready” year-round makes the actual audits less of a heavy lift and less anxiety-provoking. Audits can then be viewed as an opportunity for your program to shine!
