DQ MEPRS Audit Readiness

2012 Navy Medicine Audit Readiness Training Symposium

Plan of Action and Milestones (POA&Ms) DQ Statement Comments

A How-To Exercise

RE-T-3-D

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DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

Context, Purpose, Outcome

• Demonstrate the process to develop effective plans of actions and milestones.

• Educate audience on properly defining the issues, conducting efficient root cause analysis and developing actions and timeliness to correct program weaknesses.

• Audience will report effective POA&Ms to efficiently correct weaknesses in the DQMC and MEPRS programs.

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DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

What is a POA&M?• A document designed to identify the root cause

of a discrepancy, the actions to be taken to resolve it, and a timeline for when the actions will occur.

• POA&Ms are required when a Data Quality metric is non-compliant for 3 consecutive months. POA&Ms can be closed once a metric show 3 consecutive months of compliance.

• Standard format also includes details such as action officers, risks, dependencies, and quarterly status updates.

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DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

Identifying the Issue• Issues are a broad summarization of what is

causing the metric to be non-compliant across the whole period of non-compliance.

• Issues are not a restatement of the metric!• Issues should not be confused with Root

Causes.• Best explained by example:

– Metric: Gas gauge reads empty. – Issue: Reading is incorrect, the tank is actually full.

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DQ MEPRS Audit ReadinessDQ MEPRS Audit ReadinessRoot Cause Analysis• A Root Cause Analysis (RCA) helps identify the what,

how and why an event occurs or has occurred. Knowing why a metric is non-compliant is needed in order to put corrective actions into place. Root Cases have four primary characteristics:

– Underlying Causes

– Reasonably Identified

– Controlled by Management

– Reasonably Prevented

• Example: Faulty wire on the gas gauge cases it to incorrectly read the tank fuel level.

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DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

Risks and Dependencies• Risk is defined as the probability or threat of a damage, injury,

liability, loss or other negative occurrence that is caused by external or internal vulnerabilities, and that may be neutralized through preemptive action.– POA&Ms are used to either identify the risks of inaction (if the root

cause is not addressed) as well as the risks of action (what might happen if the POA&M is implemented).

– Risks should never be identified as “a failure to meet the metric”. – Gas gauge example: The risk of a gas gauge reading Empty is not that

it will continue to say Empty, but that you might run out of gas and be stranded.

• Dependency is defined as the relationship between conditions, events, or tasks such that one cannot begin or be-completed until one or more other conditions, events, or tasks have occurred, begun, or completed.– Gas gauge example: To fix the gauge, you are dependent upon an

electrician.FOR OFFICIAL USE ONLY

*Definitions blatantly plagiarized from: http://www.businessdictionary.com/

DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

Action Items• Action items are discrete activities that an

MTF will perform. – Must have a definite start/stop. Actions can be

used to change a recurring process, but the recurring process itself is not the action.

– Must have an Action Officer assigned. Do NOT default everything to the DQ Manager!

• Action items are specifically address a Root Cause.

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DQ MEPRS Audit ReadinessDQ MEPRS Audit ReadinessCurrent POA&M Format

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DQ MEPRS Audit ReadinessDQ MEPRS Audit ReadinessLet’s Look At What NOT To Do…..

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Using what you have learned from the previous slides, can you identify why this is not a good POA&M?

DQ MEPRS Audit ReadinessDQ MEPRS Audit ReadinessExample of a Proper POA&M

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DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

Data Quality Statement Comments

• Comments are required for metrics that fall outside the compliance range (usually less than 95%).

• Comments must identify the Issue and Corrective Action for the particular month. Process is the same as for a POA&M, but for the specific data month.

• Do Not!!– Restate the metric.

– Put the same comment each month.

– Put corrective actions that say “continuing to monitor” or “continuing to train”.

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DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

Some Examples of Not-So-Useful Comments

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DQ MEPRS Audit ReadinessDQ MEPRS Audit Readiness

Questions?

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