Zablocki, Shawn, Olsson Associates, Top 10 Tips for an Effective Audit, 2015 MECC KC

Top 10 Tips for an Effective Audit Program

Midwest Environmental Compliance Conference

May 13-14, 2015

Agenda

• Developing an audit program• Conducting audits• Audit documentation• Audit follow up• Questions

Tip #1 – Management Support

• Management support is critical to an effective audit program– Time and resource commitment to conduct the

audit– Financial commitment to correct findings– Understanding of the ultimate purpose of the

audit

Tip #2 – Define Scope and Purpose

• What is the purpose of the audit? (WHY?)– Verify Compliance with regulations– Verify compliance with company policies– Verification for higher level program such as ISO

OSHA VPP, etc– Administrative order mandating audits– Identify Best Practices – Training/education

Tip #2 – Define Scope and Purpose

• What is the scope of the audit? (WHAT?)– Define the content and standard that we are

auditing against• OSHA/EPA regulations

– Comprehensive Environmental– Comprehensive Safety– Targeted toward a particular regulation or standard

• Company Policy• External standard (VPP, ISO)

Tip # 3 – Develop Audit Protocol

• Once the scope is identified, we then need to determine how detailed is the audit is going to be– 30,000 foot view– Detailed deep dive– There are pros and cons with each approach,

essential to understand WHY we are performing the audit


• Determine the questions to be asked– If regulatory based audit, utilize the standard that

is being audited against, each point in the regulation should be an individual item looked into during the audit

– View company policy similar to a regulation and focus on key points of the policy

– External standards such as VPP and ISO will have specific protocol to use


• Questions should be developed for each component of the audit– Document review

• Based on requirements for program content, training records, etc

– Practical application• Will be based on employee interviews• Site tours

– Employee Perception• Again from employee interviews, but may ask different

questions if trying to determine perception versus compliance


• Draft all questions to have a “Yes” answer if the desired objective is met

• Define what it takes to obtain a “Yes” answer– Will all answer be either Yes or No or will there be

intermediate responses i.e. Satisfactory, Needs Refinement, Needs Improvement, etc

– Determine “verification” for each question - the criteria that each questions will be answered against

Tip # 4 – Utilize Experienced Auditors

• Key auditor characteristics• Experience• Technical knowledge• Impartial• Can be internal or external resource or a combination

of both• Must be able to decipher what is reality and what is not

Tip # 4 – Utilize Experienced Auditors

• If using more than one auditor, be certain all auditors are calibrated to ensure consistent results– Review audit questions in advance of the audit– Have multiple auditors conduct the same audit so

they can calibrate their responses

Tip # 5 – Announced vs Unannounced

• Determine if audits will be announced or unannounced– Announced

• Typically more efficient use of time and resources• Scheduling ensures that all necessary personnel for the site are present

during the audit• Allows sites time to “prepare” for the audit

– Unannounced• More accurate determination of sites true compliance status and

organization• May be less efficient due to facility personnel not being present and files

not being organized and readily available• May frustrate plant management

Tip #6 – Develop a Game Plan

• Establish ground rules– Handling of discovery of critical deviation

• Internal notifications• Are external notifications required, if so, how handled• Will audit continue• Start of self disclosure clock

– Scheduling of employee interviews– Will end of day recaps be held

• Conduct opening meeting outlining the scope and intent of the audit


• Begin audit with document review– This allows you to make notes of what to look for

in the field and also specific items to ask employees about during employee interviews

– This also allows the auditor to inform the facility of any missing documentation so that it may be tracked down during the remainder of the audit


• Perform site tour– Look for specific evidence that the written

programs are indeed being implemented in the facility. Examples…• SWPPP Inspections indicate storm drains clear and free

of debris…are they?• SPCC inspections indicate that containment area drain

valves are closed and locked… are they?


• General Comments– Keep in mind that there is still a manufacturing

operation going on and the auditor is there as a service to the plant

– Remember that the auditor is simply there to gather the facts and then report the facts. Throughout the audit do not appear shocked, form opinions, or provide comments based on speculation or opinions• “It is what it is and that’s what it is”

Tip #7 – Employee Interviews

• Conducting Employee Interviews– Interview should be between auditor and employee

only, unless Union contract specifies otherwise– Ensure the employee is aware that the interview is

confidential and that there will be no consequences for honest feedback

– Remember that employees are a very vital source of information so feel free to expand upon a conversation if it is pertinent to the audit scope

– Ensure you get a representative sample of employees

Tip #7 – Employee Interviews

• When compiling results, look for trends in employee responses

• A disgruntled employee is not uncommon whereas 75% of responses discussing a specific issue or concern bears much more weight.

Tip # 8 – Proper Audit Documentation

• Auditor should based comments and findings strictly on their own observations– If it’s not documented, it is not done

• May make note to the effect that the practice appears to be in place but documentation is lacking

• For credibility, do not take facility’s “word for it”

– All comments and findings should be factually based.• An audit is a snap shot in time of the actual conditions that exist• An audit is not intended to ask the auditor their opinion of

things• Make notes that you allow you to best describe the actual

conditions


• There should be some understanding of how the audit findings are to be documented in report format before the report is written. Different companies prefer to see the results in different ways

• JUST THE FACTS MA’AM!– Discussion in the body of the report and in the audit

checklist itself must remain with strictly the details actually observed during the audit and in some cases follow up actions taken between the on site audit and the issuance of the report.


• Avoid drawing conclusions or making judgments regarding compliance with regulations. – For example stating “at the time of the audit, the

facility did not have documentation supporting preventative maintenance on control devices was being performed” is more appropriate than stating “the facility is in violation of its air permit because there was no documentation to show control device maintenance was being performed.”


• Issue a draft report for review and comment prior to issuing a final report– This allows the facility to review and ensure that the

auditor has properly captured what was observed during the audit and allows any potential discrepancies to be addressed prior to finalizing the audit

– Draft report must clearly indicate that they are “draft” documents.

– While you want to ensure concurrence on report content, do not allow the facility to write the audit report.

Tip # 9 – Establish Corrective Action Plan

• It is important and in some cases required by regulation to document corrective actions taken to address audit findings

• Findings should be prioritized and responsibility assigned to addressing the finding.

Tip # 9 – Establish Corrective Action Plan

• Set reasonable yet aggressive timelines for closing out all findings. – Do not set yourself up for failure with over aggressive

timelines, but ensure that critical items are addressed in a timely manner

– Often times 90 – 180 days is a reasonable time frame to target addressing administrative findings, whereas capital improvement may take 18 months or longer to fully compete. • For longer timeline items provide interim measures to

demonstrate that safety is not being compromised while the final solution is being implemented.

Tip # 10 – Document Corrective Actions

• Document all action taken including intermediate steps to address audit findings– Meeting minutes which show discussion on audit findings– It is best if work orders and purchase orders generated to address

findings are kept with the audit report with a clear reference linking the finding to the work order or purchase order.

– Training documentation, program revisions and Sop updates can either be kept with the report or have a reference in the report directing you to the location of the revised document

• Want to be able to show a clear paper trail that will lead someone to the verification that the finding was addressed

Additional Audit Considerations

• Audits should be approached as a means to identify deficiencies and should not be taken personally

• Be careful of “scoring” audits and how those audits scores are interpreted and used

• It is extremely helpful for EHS personnel to take part in audits of other facilities if possible

• Audits should be used to accentuate the positive and not only point out the negative, often times good best practices can be discovered by performing audits and those practices can then be shared to improve other operations.

Additional Audit Considerations

• Attorney Client Privilege – Can audit results be protected???– Very specific rules to be able to effectively invoke

Attorney client privilege• In general “Privilege” applies to communication

between and attorney and client– Question in corporations of who is the client?

• For audits – Defined scope – Conducted at the request of the attorney– In anticipation of litigation

QUESTIONS??Shawn Zablocki

Industrial Program Leader Olsson Associates

[email protected] 402-938-2414

Cell 402-350-7101

mailto:[email protected]