Introduction: It is recognized by the Faculty of the School of Medicine that periodic audits of ongoing activities are a critical element of institutional management. Appropriately conducted audits serve to identify areas in which the institution is at risk to external entities for lapses in administration of contractual obligations and oversight functions. Audits undertaken to identify such areas, termed “Risk Management Audits”, are a valuable tool to guide faculty and administration in the proper conduct of clinical, research and educational activities and they may limit institutional liability if problems are prospectively identified and corrective actions or procedural changes are undertaken. Audits, termed “For Cause” audits may also be required to investigate allegations of wrongdoing on the part of faculty or administrative officials. The ability to conduct such audits is also a critical element of institutional management both from the standpoint of institutional liability and from the standpoint of the appropriate use of institutional resources. The development of auditing policy and the conduct of audits is a joint responsibility of the School of Medicine administration and its Faculty.
Audits are, by definition, undertaken by third parties not involved in the specific activity being reviewed. In order for audits to be effective and efficient, several critical elements must be in place:
- Institutional personnel must have faith in the integrity of the audit and of the officials directing the audit.
- Auditing personnel must have an in depth knowledge of standard practices in the area under review.
- Auditing personnel must be aware of explicit guidelines in the area under review as well as the specific communications to those being audited as to how institutional personnel have been educated about these practices.
- Auditing personnel must have access to all necessary data to form conclusions about the area under review.
- Personnel being audited must be provided a detailed review of the conclusions of any audit and be given an opportunity to appeal any disagreements to a party other than that conducting the audit.
With these principles in mind, the following procedures will be in place for all current and future auditing activities undertaken by the School of Medicine and University Physicians, Incorporated.
- Education and Communication. Effective communication and education regarding institutional policies should be viewed as the primary approach to ensuring adherence with institutional policies. It will be the responsibility of the Institution and its administrative officials to clearly communicate institutional policies regarding activities that will be subjected to auditing. It is recognized that the gathering of data may be important in formulating proposals for changes in institutional administrative policies. If audits are undertaken for this purpose, it is recognized that the purpose of such audits is to generate information that informs policy and that individuals and programs will not be administratively or fiscally penalized by findings of such audits.
- Prior Notification. Awareness of the areas in which audits may be conducted serves as a strong inducement to maintain appropriate records and to adhere to institutional policies. Thus, it will be the responsibility of the Dean of the School of Medicine to communicate with faculty and administrative officials regarding audit policy and areas in which “Risk Management Audits” will be undertaken. When a program, a faculty member, or an administrative official is the subject of a Risk Management Audit, it will be the responsibility of the administrative official authorizing the auditing program to be certain that the faculty member or administrative official under review is prospectively notified about the purpose of the audit. It is recognized that certain “For Cause Audits” may require that the audits be initiated without the knowledge of persons under review. In this case, prior to the initiation of the audit a written document must be generated that identifies the person or activity being reviewed, the specific purpose of the audit, and a commentary as to why it was deemed that prior notification would jeopardize the conduct of the audit. This document must be reviewed and signed by the Dean and maintained in a confidential file that can be reviewed by the faculty member or administrative official being reviewed at the conclusion of the audit.
- Education of Auditing Personnel. It is recognized that activities of the faculty and administrative officials are often technically complex and that such activities may be outside the area of expertise of those undertaking audits. Accordingly, it is the responsibility of the official authorizing an audit to be certain that auditing personnel have been properly instructed in the areas under review prior to the initiation of the review. This may require that faculty or others be retained as consultants to the auditors to provide information regarding standard procedures in the specific area being reviewed. Auditing personnel must also be explicitly educated with respect to the areas to be reviewed. Prior written guidelines regarding necessary documentation must be provided to the auditors and must be made available to those under review during or after the completion of the audit.
- Opportunity for Interaction with Auditors. The credibility of specific audits and of institutional auditing policies is closely tied to the accuracy of audits undertaken. It is recognized that auditors may make erroneous conclusions for a number of reasons including a lack of expertise, inappropriate prior instruction, insufficient availability of documentation. Many of these problems can be effectively addressed by insuring that auditing personnel have appropriate expertise, well-documented instructions, and clearly laid out procedures. In the case of Risk Management Audits, consultation with the faculty member or administrative official during the course of the audit may be en extremely valuable tool in fostering cooperation, providing better access to documentation, and in maintaining trust in the audit and the auditing process. Therefore, it is expected that audit personnel will make efforts to interact with those being reviewed during the audit to resolve any confusion about procedures and/or documentation. It is also expected that faculty and/or administrative officials whose programs are being audited will interact with auditing personnel in a collegial fashion and will provide all necessary assistance to auditors when requested. In the case of “For Cause Audits”, if there are areas in which the auditors are uncertain as to procedures or standard practice, it will be their responsibility to seek appropriate guidance from the official authorizing the audit. In certain cases, confidential consultation with individuals with specific knowledge in the area being reviewed may be required. Such advice may be requested from individuals within or from outside the School of Medicine.
- Opportunity for Review of Findings. In the case of Risk Management and For Cause Audits, it is the responsibility of the official authorizing an audit to communicate the findings of the audit clearly to the individual whose program(s) is/are under review. The notification of supervisors or other personnel of the findings of an audit does not relieve the official of this responsibility. All findings of the audit must be clearly documented and the individual being reviewed must be given an opportunity to respond during an appropriate time interval. It is recognized that the faculty and officials have multiple ongoing commitments, and, thus, the time allowed for a response to the findings must be realistic and must consider the nature and scope of the required response and the nature of the ongoing responsibilities of the faculty member or administrative official being reviewed. The response to the findings of an audit should be reviewed by the auditing team and by the official authorizing the audit. A written response to any issues that remain under dispute must be provided to the faculty member or administrative official in a timely fashion, and, in any event, before any adverse fiscal or administrative actions are undertaken.
- Opportunity for Appeal of Findings. No adverse fiscal or administrative actions may be taken without providing the individual being reviewed an opportunity for an appeal to a party not involved in the initiation or conduct of the audit. This is essential in that it is recognized that those authorizing and/or conducting an audit may be conflicted with respect to providing an impartial and objective response to an appeal. In the event of an appeal of the findings of an audit, the Dean and the Faculty Officers will jointly establish a panel of five individuals who will confidentially review the areas under dispute. The Review Panel will consist of two Members of the Executive Faculty and two administrative officials not involved in the audit and without conflicting relationships with the individual being reviewed. The Review Panel will be chaired by the Associate Dean for Faculty Affairs if a faculty member is under review and by the Associate Dean for Administration if an administrative official is under review.
- Applicability of Audit Procedures to Reviews Undertaken by Bodies External to the School of Medicine and/or University Physicians, Inc. These procedures are recognized as being valid principles under which all audit activities involving faculty or administrative officials of the School of Medicine will be conducted. These principles will be applied to all audits undertaken by the School of Medicine or by University Physicians, Inc. It is also recognized that audits may be initiated by entities external to the School of Medicine and/or University Physicians, Inc. These procedures must be incorporated into any agreements made between the School of Medicine and/or University Physicians, Inc. and Affiliated Institutions. In addition, to the extent possible, it is expected that these procedures will be communicated to any external entities undertaking audits of activities within the School of Medicine and that efforts will be made to conduct the audits in a fashion as close as possible to the conditions outlined in this document. In all cases, whether the audit has been initiated within or outside the School of Medicine and/or University Physicians, Inc., faculty and/or administrators will be provided an opportunity to appeal the results of an audit before funds are removed from accounts for which faculty and/or administrative officials are responsible. Although funds may be escrowed pending the appeal of an audit, no funds may be removed from an account under any circumstance without prior notification of the person directly responsible that account.