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What Difference Does It Make?

Not a reference to The Smiths first top twenty single back in 1984 (yes I’m old enough to remember – I wish I still had all of that hair) – but a phrase that has enormous importance to everyone working in the National Health Service and particularly us at Audit Yorkshire.

I have sat in a lot of interviews over the years where we have asked nervous candidates why they want to come to work as an auditor or as a local counter fraud specialist in the NHS. I’ve heard many answers to that question (my favourite is probably still - ‘for the free healthcare benefits package’) – but one of the most common answers is ‘to make a difference.’

I imagine that this would be a common answer in interviews for most roles in the NHS.

I have to admit that this desire to ‘make a difference’ was one of the main drivers that encouraged me to move my career from accountancy in the commercial sector to audit in the NHS. It seemed to me that Audit work covered all of the key systems of control within NHS organisations – and that therefore there was a huge potential to make a difference – to spot opportunities, to make improvements, to recommend changes and to see the real benefits accruing from those actions we have recommended.

Recently I have been thinking more and more about how we make sure that real benefits do accrue from our recommendations. This is sometimes difficult as the auditor is able to shape the recommendation for action - but making the action happen and ensuring it is applied in the most effective way possible is dependent on the efforts of the managers and staff in the organisation assigned responsibility for taking the action. 

I was recently invited to give a presentation to the Clinical Audit team at Mid Yorkshire Hospitals NHS Trust on the subject of Effective Action Planning.  It was a really excellent session and we realised that we have a relatively common approach in terms of making sure that action plans are designed to be as effective as possible.  We identified a list of some of the key facets of Effective Action Planning:

  • The key feature is that Action Planning needs to be SMART at EVERY stage of the action plan process to promote effectiveness and to increase the ‘making a difference’ factor. SMART is a common acronym with the following definitions: Specific, Measurable, Assignable, Realistic, Time-related.

  • Being clear up front about who will agree actions and assign actions – the approach to action planning needs to be agreed before audit work even gets started. This approach ensures there expectations are set in advance and there are no surprises in terms of responsibilities. The approach also fosters stakeholder engagement, interest and ownership.

  • Use a consistent template and format for capturing actions. This ensures that all key information relating to an action are fully captured in accordance with a set format. This format of the action plan should (as a minimum) ensure that the action is fully described, that the issue to be addressed and the potential outcome/benefit of taking the action is described, that the person responsible for taking the action is fully identified, that the level of priority attached to the action is explained, that any issues to be taken into account in terms of taking the action have been recorded and that the date the action is due to be completed by is recorded.

  • Be clear on why the action is needed – in particular describing the potential impact of taking and/or not taking the action (including quantification where possible) and fully explaining the potential benefits attached to taking the action.

  • Getting agreement on action plans is really important. Further than that – taking steps to ensure that key managers in the organisation see the benefits of championing the implementation of actions is key and promotes efforts to maximise the impact derived from actions taken.

  • Actions agreed at the most senior level and with Director level oversight are likely to be those which have the biggest impact in terms of driving improvements.

  • Actions should be graded (prioritised) in a consistent manner – not all actions need to have a high profile and many recommendations and actions may address minor issues. It is really important that both organisational management and Auditors focus their time on the key actions that will generate substantial benefits or address key risks. A robust prioritisation system is key to this.

  • Implementation dates should be clear, agreed, and achievable. A set date should always be agreed – some actions may need to be applied on an ongoing basis – however there should always be a clear date by which as assessment can be made on the effectiveness of the action in terms of addressing the issue originally found or achieving the beneficial impact required from taking the action.

  • Being clear on who is responsible for each action. This should be one named person wherever possible. Where multiple people are involved with taking action there should always be one clear person with overall responsibility for championing the implementation of the Action.

  • There should be a robust and transparent process for following up actions to make sure that the agreed actions have been implemented and have delivered the intended impact.

We agreed that this final step is absolutely crucial in terms of getting best value from audit work undertaken and in terms of ‘making a difference.’ We discussed a list of some of the key facets of follow up:

  • All the above ‘Effective Action Planning facets’ need to have been applied
  • There needs to be a routine, clear and consistently applied process in place to confirm that actions have been undertaken within the agreed timescales and for highlighting and reviewing those actions that are not addressed within these timescales.
  • There needs to be top level support and profile for these routines to ensure that actions are being undertaken as agreed and are delivering the benefits required on a timely basis. This needs to include an element of challenge when actions do not progress as envisaged.

  • There should be a process which provides a good level of independent assurance on the implementation of actions.

  • The whole process needs to be SMART in terms of providing accurate and timely assurance information and in terms of quantifying the impact of actions taken.
  • Management information underpinning the process should be clear, in a common format, sufficient, not overly complex and focussed.

Audit Yorkshire is currently reviewing its standard approach to recommendation follow up. The review to date has highlighted that Audit Yorkshire already adopts a really robust approach in line with the best practice outlined above.  It is really pleasing to see the impact of the recommendations we make – and the initial review work indicates that Audit Yorkshire can respond to The Smith’s question with the words ‘A really big difference!’