What Are the Compliance and Internal Audit Department Services?
Children's of Alabama's (Children's) Board of Trustees and Senior Management entrusts the Compliance Officer and the Compliance and Internal Audit Department to conduct ongoing reviews of Children's operations; monitor compliance with regulatory requirements, JCAHO Standards, internal policies; and evaluate the efficiency and effectiveness of controls and accuracy of financial records. The department serves as an independent consulting, monitoring, and auditing function within Children's as a service to management and staff in fulfilling the organization's compliance and ethical responsibilities.
The Compliance and Internal Audit Department assists management by providing emerging regulatory and best- practice information, searching for causes of inefficiencies or problems, and providing analysis and recommendations management may need to improve operations or form corrective action plans.
What Authority Does the Department Have?
The Compliance and Internal Audit department is authorized for full access to all records, properties, systems, and personnel necessary to perform audits and review activities effectively. The department is responsible for treating sensitive information in a confidential manner. Auditors are expected to be courteous and professional. All personnel are expected to provide all possible assistance to facilitate the review.
Why Am I Being Audited?
We work with management to identify risks in all departments based on federal and state regulatory guidance, JCAHO requirements, and internal policies. Audits are scheduled by priority according to risk and date of last review. Believe it or not, some departments are audited because they have requested an objective review!
We also perform investigations of concerns reported through the Compliance Hotline and Reporting Website. The Compliance and Internal Audit Department is committed to providing a safe, open forum for employees, physicians, affiliates, contractors, and agents of Children's to report concerns regarding any facet of its operations. Children's of Alabama supports "doing the right thing." Good faith reporting must never result in retaliation or retribution. Our policy and commitment is to provide employees this privilege in hopes of reducing unnecessary or unwarranted liability and jeopardizing the services we provide to children.
What Happens When My Department Is Audited?
The Auditor begins by speaking with management and key personnel to explain the audit process. The Auditor needs to get a good understanding of how the department functions from the experts - YOU! This means the Auditor will ask questions, review and discuss general policies, and ask management and staff about concerns they may have. The Auditor will also ask to see evidence the department performs specific internal controls. The Auditor will request data and copy reports or other documents for testing general assumptions about controls and operations. The conversations and research help the Auditor plan steps to take for performing a productive review that meets objectives of all involved.
In audits, we use the "no surprises" approach. In other words, the Auditor will discuss findings or issues with management as they are identified. The Auditor will be available for questions at any time during the audit process.
How Are Results of an Audit Reported?
After the test work is completed, the Auditor creates a draft report. This report will list the Auditor's findings and recommendations. The report may include operational strengths and best practices identified. The draft report is provided to the appropriate vice-president, department manager, and other personnel that were significantly involved in the audit.
An exit conference, via email or meeting in person with all involved, will be conducted to review and solicit feedback on the information reported. At this point, the Auditor may revise the draft report to include clarification and management responses. The Auditor will be available to answer questions throughout the audit process and will collaborate with management to develop action plans and implementation dates for each item of concern. These action plans will be included in the final audit report.
Who Receives The Final Audit Report?
When the draft report is revised, completed, and approved by all involved in the audit, a final report will be forwarded to Senior Management, the department manager, and other appropriate personnel. Audits are reported to the Finance and Audit Committee of the Board of Trustees of Children's.
What Do I Do After The Audit Report Has Been Released?
Management should communicate pertinent audit findings to appropriate staff members and implement the related action plans. These corrective actions are the responsibility of management. Therefore, the Auditor's review and final report do not, in any way, relieve other persons in the organization of the responsibilities assigned to them.
Is A Follow-Up Procedure Performed?
Yes. A follow-up audit is performed typically within 6 months to 12 months after issuing the report. Management is asked whether the action plans were implemented, supporting documentation may be requested, and additional testing may be performed to ensure action plans are working as anticipated. The results of follow-up audits are reported to Senior Management and the Board of Trustees.