260917 introduction to managing and conducting an ... · pdf fileseminar internal-external...

Organised By : In Partnership With :

Session : A3a

Prof. Dr. Hanim Bt Salleh, C. Eng (UK)

26th September 2017

1.30 p.m – 3.30 p.m

INTRODUCTION TO

MANAGING & CONDUCTING

AN INTEGRATED INTERNAL

AUDIT

Seminar Internal-External Quality Assurance 2017

TENTATIVE

Time (min)

20 Part 1 1.1 Learning Outcome1.2 Introduction to Audit1.3 Overview of Audit Process

30 Part 2Discussion

Audit Preparation & Conducting Audit

30 Part 3 3.1 Integrated internal quality audit & university strategic direction. 3.2 Value-based (shariah-based)3.3 Risk-based3.4 Academic-based3.4 Issues & Challenges

30 Part 4 Discussion &Presentation

Conducting an integrated audit


Part 1Part 1Part 1Part 1

1.1 Learning Outcomes1.2 Introduction to Audit1.3 Audit Process


By the end of this workshop, participants will be able to:

1. Explain how to manage and to conduct practical internal quality audit in

general

2. Explain how to integrate the process approach into risk-based, academic-

based and value-based (shariah-based) internal quality audit.

3. Explain the challenges and good practices in conducting the integrated

internal audit.

LEARNING OUTCOME


Importance of Audit

Looking at the overall process

Auditing Conformity

Auditing effectiveness

Approving supplies / subcontractors

Assessing for certification

Way of improvement


TERMS AND DEFINITIONS

• Audit Criteria

– Set of policies, procedures or requirements used as reference against which audit evidence is compared

• Audit Evidence

– Records, statement or fact or other information which are relevant to the process


IMPORTANT TERMS AND DEFINITIONS

• Audit Plan

– Description of the activities & arrangement for an audit

• Auditee

– organization/unit being audited

• Audit CLIENT

– organization or person requesting an audit


Audit scopeAreas to be audited, e.g.:

Design & Development Of Education Programme

Provision Of Education Services For Undergraduate & Post Graduate Programme

Management Of Research & Consultancy

Operation Of The Overall Support Services


METHODOLOGY

Document

Review

Site Visit

Interviews

Observation

Collect

Evidence


AUDIT process

Audit Preparation

Conducting The Audit

Audit Report

Follow Up Audit


Audit CycleAudit CycleAudit CycleAudit Cycle


AUDIT PREPARATION

Prepare resources

Obtain relevant document

Review the planned date

Inform people to be audited

Pre audit INFORMATIOM

Prepare audit checklist

•With the standards, Quality manual

• Procedure, work instruction, spec, forms, Observes work practices, Previous report

Familiaries yourself


CONDUCTING THE AUDIT

• Opening meetingi. Introduction to auditee and explain purpose of your coming

ii.Review scope and purposeiii.Explain auditing processiv. date & time of closing meeting

• Practicesi. Is the procedure followedii. Could the procedure be improvediii.Could work practices be improved


TYPES OF AUDIT FINDINGS

•POSITIVE FINDINGS

�GOOD PRACTICE, CONFORMITIES

•NEGATIVE FINDINGS

�NONCONFORMITIES

•OBSERVATIONS

� OPPORTUNITIES FOR

IMPROVEMENTS


AUDIT REPORT

• WRITE UP THE INTERNAL AUDIT REPORT

i. EVEN IF THERE ARE NO PROBLEMS

ii.GIVE POSITIVE FEEDBACK TOO!

• ATTACH SUPPORTING DOCUMENTATION

i. COPIES OF RECORDS THAT DEMONSTRATES YOUR FINDINGS

• CONTACT CIA FOR ANY ISSUES


AUDIT REPORT

• Finding statement writing (report making)

�In order to make a report which understandable by auditee & traceable for future follow up , findings statement should consist the component below :-i. Problem/Findings – Statement of the problem encountered, suggested the statement of weakness against iso requirement

ii. Objective Evidence – Statement of evidence founded

iii.Reference/Requirement – Statement of the audit criteria not fulfilled (this not comply with iso requirement)


NCR (Non-Conformance Report)

• NCR WILL BE ISSUED IF PRODUCT OR PROCESS DOES NOT COMPLY WITH……..

1. QUALITY Manual, Procedure, CIRCULAR & ETC

2. ISO/standard REQUIREMENT ( 9001:2008 &

1900:2005)

3. SET OF SPECIFICATION

4. WORK INSTRUCTION

5. SUPPORTING DOCUMENT (REFERENCE

DOCUMENT)


AUDIT REPORT

• Finding statement writing (Sample)

i. Sample of correct statement

i. Incomplete Statement


Closing meeting

• Thanks the auditee for their cooperation and time

• List the positive things that you observe or found during the audit

• Present the criticality of the observations - highest first

• Present findings based on facts


After the audit

•Complete the audit report

•Commit to a time of delivery

•Send the audit report (observation/NCR) to the auditee using system

•Follow up with the late responses (ncr & ofi)


Part 2: DiscussionPart 2: DiscussionPart 2: DiscussionPart 2: DiscussionYour institution will be having anexternal audit, so you will need toplan for an internal audit. Plan someof the activities required in order toprepare for the internal audit?Suggest some good practices inconducting an internal audit in yourinstitution.



3.1 Integrated internal quality audit & university strategic direction. 3.2 Value-based (shariah-based)3.3 Risk-based3.4 Academic-based3.5 Issues & Challenges


STRATEGIC PLANNING

Clause9.3.1

Management

Review

Top management shall review the organization’s

quality management system, at planned intervals, to

ensure its continuing suitability, adequacy,

effectiveness and alignment with the strategic

direction of the organization.

Mapping Review

2.12.2


STRATEGIC PLANNING

BOLD 2025Building Opportunities Living

Dreams

3

10

30

STRATEGICGOALS

STRATEGICOBJECTIVES

STRATEGICINITIATIVES

Academic Audit

Quality ManagementSystem

1

QM

11

GP

135

PC32

WI


QUALITY FRAMEWORK & POLICY

To achieve success with

commitment towards Core Values

Quality Policy


ADMINISTRATIVE QUALITY ECOSYSTEM


ACADEMIC QUALITY ECOSYSTEM


RESEARCH ECOSYSTEM

IEPRe(Institute of Energy Policy & Research)

� Direct funding from EC / TNB for Chair in Energy Economy

IICE(Institute of

Informatics and Computing in

Energy)

IEI(Institute of Energy Infrastructure)

UNITEN R&D(UNITEN R&D SDN BHD)

• Research Funding from Industries leveraging on

Section 34B, Income Tax Act 1967

• Drive IP & commercialization

BOLD 2025RESEARCH EXCELLENCE

G l o b a l l y C o m p e t i t i v e ; E n e r g y F o c u s e d U n i v e r s i t y

IPE(Institute of Power

Engineering)

ISE(Institute of

Sustainable Energy)

� Direct funding from AAIBE for Chair in Renewable Energy

iRMC(INNOVATION & RESEARCH MANAGEMENT CENTRE)

• Research funding from MOHE, MOSTI, Government

Agencies, International Agencies• Develop research roadmap for UNITEN

• Develop research capacity for UNITEN

H I G H P E R F O R M I N G W O R K F O R C E

THE

ENERGY

SPHERE


INTEGRATED AUDIT

NO. OF QMS DOCUMENTS179

• 32• 1

• 135• 11

General

Procedure

Process

Control

Work

Instructions

Quality

Manual

111Technical

& Administrative

24Academic & Research

Technical &

Administrative


INTEGRATED AUDIT

COPPA /

COPIA/ Self-

Accreditation

QMS ISO 9001

& MS 1900

Value-based

Shariah

Compliance

Group

Internal

Audit


INTEGRATED AUDIT

Comply with Accreditation Requirement


INTEGRATED AUDIT

Fulfillment of Regulatory Requirements �� Internal Assessment (Self-Review)


INTEGRATED AUDIT

To direct and control an organization with respect

to quality in:

Documents

Processes

People


Management Responsibility

Values Management

Product Realisation

Measurement, Analysis and Improvement

Resource Management

ProductRequirements

Customers Customers

Satisfaction

Input Output

Shariah requirements

Shariah.based quality management system

UNITEN QUALITY MANAGEMENT

SYSTEM


SHARIAH IMPLEMENTATION

ICV Activities

ShariahCritical Point

ICV Audit

Internal Audit

ICV Survey ICV Awards

Food Operator Inspection

Smoking Inspection


ICV

Compliance with all laws,rules and guidelines set byUNITEN

Organizations depend on theircustomers and therefore shouldunderstand current and futurecustomer needs, should meetcustomer requirements and striveto exceed customer expectations

United as a team and supporteach other in achieving thevision and mission UNITEN

Feeling and exhibiting concernand empathy for others. Caringis not just a way of feeling, it isa way of behaving

INTERNALIZING CORE VALUE

(ICV)


TEAMWORKCUSTOMER

FOCUSINTEGRITY CARING

� Adhere to all set rules,regulations andguidelines.

� Perform to our bestability with very highstandards whilstcontinuously improvingthe quality of ourservices.

� Adopt an open andhonest attitude in allaspects.

� Deliver products andservices to customers aspledged.

� Have pride incontributing towardsUNITEN’s success

� Deliver high qualityproducts and services atpar with premierinternational corporatebodies.

� Provide best possibleservices to customers.

� Realize that customersupport is important toUNITEN.

� Understand customersneeds and to fulfill to thebest of our capability.

� Retain customers’ loyaltyby continuouslymonitoring their needs.

� Trust and support eachother, building goodrelationships and goodteam spirit.

� Give constructivefeedback to each other,committed to everyone’sdevelopment

� Involve each other,working together acrossboundaries, seeking ideasand sharing solutions

� Working togetherto achieve our strategicgoals and objectives.

� Conduct our business with UNITEN’s interests in mind.

� Acknowledge employees contribution and be sensitive to their needs.

� Assist employees to develop their potentials.

� Serve our customers and fellow employees in the same way we would like to be treated.

� Always be sensitive to the needs of the society and the environment.

� Undertake social obligations without jeopardizing UNITEN’s interest.


(ICV) - PRINCIPLE


VALUE BASED ON SHARIAH

(ISLAMIC PRINCIPLE)

138 QMS Document (Process Control) are linked to the

principle of shariah/ Core

values

Online Quality

Management System

4

Core

Values

Integrity

Customer Focus

Teamwork

Caring

3

Sources

Hadith

Scholars Opinion

(Pendapat Ulama)

Quran


VALUE BASED ON SHARIAH

(ISLAMIC PRINCIPLE)

Procedure – Issuance of ID For Student, Staff & Temporary (RA, Part Time & Contractor)Principle Of Shariah :

Customer Focus

Procedure – Student Selection & AdmissionPrinciple Of Shariah : Caring & Integrity

Procedure – Performance Management SystemPrinciple Of Shariah :

Teamwork

EXAMPLES OF PROCESS CONTROL


Integrity Customer Focus Teamwork Caring

College Of Foundation & Graduate

Studies (CFGS)

Marketing & Corporate

Communication (MCC)

Human Resource

(HR)Student Affairs Centre (SAC)

Integrity Talk Open Day Team Building

Birthday wishes from Management

Fun Run Ihya’ RamadhanFriday Morning

Talk

UNITEN Lecture Series Staff RecognitionTotal Wellness

Big Cleaning Day

Career Fair

UNITEN Customer Centre

Staff Integration Sports

Hari Raya Celebration

Birthday Celebration

Integrity Audit

Smoking Inspection

ICV Awards

Halal Certification

Integrity Award

IMPLE

MEN

TER

AC

TIV

ITIE

S

AKC Award


(ICV)


ICV ACTIVITIES

Big Cleaning

Day

Ihya Ramadhan

Vice Chancellor

Aspiration

Qurban

Staff Integration Sport

UNITEN Open Day

UNITEN Customer

Centre (UCC)

Staff Recognition


INTEGRATED AUDIT

135 QMS Document (Process Control) are linked to the

principle of shariah/ Core

values

Online Quality

Management System

4

Core

Values

Integrity

Customer Focus

Teamwork

Caring

3

Sources

Hadith

Scholars Opinion

(Pendapat Ulama)

Quran


EXAMPLE OF PROCESS CONTROL

Procedure – Issuance of ID For Student, Staff & Temporary (RA, Part Time & Contractor)Principle Of Shariah :

Customer Focus

Procedure – Student Selection & AdmissionPrinciple Of Shariah :

Teamwork

Procedure – Performance Management SystemPrinciple Of Shariah :

Caring


VALUES MANAGEMENT AUDIT

291 Respondents

300 Target

Employees

30 Questions

2Sections

5 Scale

Duration : May 2017 – Jun 2017

SCOPE OF SURVEY QUESTION


23Risk

Strategic Risks3

Operational Risks20

RISK REGISTER


NO OWNER CONTROL OWNERS RISK

1. VC SPCUnable to gain global recognition within

targeted timeline

2.VC

SPC

Unable to effectively compete with other

higher learning institutions

3.VC

SPC

Unable to effectively compete with other

higher learning institutions

STRATEGIC RISKS


NO OWNER CONTROL OWNERS RISK

1. DVC 1Marketing, Registrar,

Colleges, IO

Low volume and low quality of local and

international students

2. DVC 2College, SAC, UIC,

SCA,UECUnable to produce holistic graduates

3. DVC 3 Research CentreUnable to deliver expected research outcomes

(including commercialization)

4. DVC 4 Colleges, TLC, ITMS, SPCInability to fully adapt to latest educational

technology

5. HR TLC, Colleges Unable to Achieve High Competence Workforce

6. PIC1 PMOIneffective implementation of procurement

process by Project Manager/ Initiator

7. PIC2 OSM Insufficient endowment fund

8. PIC3 OSM, YCU, SCA, TAZU Insufficient scholarship

9. PIC4 Security Security breach by internal and external parties

10. PIC5Marketing, Corporate

CommunicationUnable to effectively to brand UNITEN

OPERATIONAL RISK


Risk Code Risk Parameter Likelihood Risk Rating

R1 Catastrophic Almost Certain High

R2 Major Unlikely Significant

R3 Moderate Likely Significant

R4 Major Unlikely Significant

R5 Minor Moderate Medium

R6 Minor Likely Medium

R7 Moderate Moderate Significant



R10 Moderate Unlikely Medium


R12 Minor Likely Significant

R13 Minor Almost Certain Significant

R14 Minor Moderate Significant

R15 Moderate Moderate Significant


R17 Minor Likely Significant

R18 Moderate Unlikely Medium

R19

QAC will monitor Risk

Rating by each of risk code

in order to evaluate

whether action taken is

effective or not. Effective if

rating change from worst

to better

9.3.2 (e) : The effectiveness of action taken to address risk

and opportunities

• Data collection half yearly basis


CQI- COPPA COPIA


ALIGNMENT OF COPIA & COPPA REQUIREMENTSINTO THE QMS DOCUMENTS (ISO 9001 & MS 1900)

NO UNITEN’s CORE PROCESSCOPIA/COPPA REQUIREMENT

S

1. Teaching & Learning Area 1,2,3,4,5, 6, 7, 8, 9

2. Research Centre Area 6, 8 & 9

3. Human Resources Area 5 & 9

4. Facility & Development Management Area 6 & 9

5. Finance Area 6 & 9

6. Sports & Cultural Facilities And Residential(SAC)

Area 4 & 6

7. Registrar Area 4 & 9

8. Library Area 6 & 9

9. Student Accommodation Area 6 & 9

10. ITMS Area 6 & 9

11. Marketing & Corporate Communication Area 6 & 9

12. Sponsorship, Career, & Alumni Area 4, 6 & 9

13. Strategic Planning & Quality Area 1 & 9

Integrated Audit Manual, which correlates and integrates between the requirements of UNITEN core processes, COPPA and COPIA and MS ISO 9001 & MS

1900


MAPPING OF SOP’s TO COPIA & COPPA FOCUS AREAS

COPPA /COPIA Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9SOP’s

ACA-750-001:Development and Updating Teaching Portfolio

√ √ √ √

ACA-750-002: Preparing Examination Paper

√ √ √

ACA-750-004: Examination Invigilation

√ √

ACA-750-005: Preparing Examination Results

√ √

ACA-750-006: Handling Students Appeal and Remarking

√ √

ACA-750-007: Implementation of Continuous Assessment for Students

√ √ √

ACA-750-008: External Examiner and Industrial Advisory Panel Nomination and Appointment Process

√ √

ACA-750-009: Managing The External Examiner’s Visit.

√ √ √

ACA-750-010:Managing The External Examiner’s Report and The Industrial Advisory Panel Recommendation.

√ √ √

ACA-750-011:Introduction of A New Course

√ √ √ √


MAPPING OF SOP’s TO COPIA & COPPA FOCUS AREAS

COPPA /COPIA Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9SOP’s

FIN-750-014Procedure Approval of BKKM

√√

HRM-750-001 Recruitment and Placement Process for Technical & Administration Staff of Universiti Tenaga Nasional

√ √

HRM-750-002 Promotion Exercise of Academic Staff

√ √

HRM-750-003 Promotion Exercise of Technical & Administration for Non-Executive Staff.

√ √

HRM-750-019 Process of issuing the offer letter for part-time lecturer

√ √

HRM-750-021 Application To Attend Public Program (To Present Research Paper In Seminar/ Workshop/Conference/Symposium And Publish Journal In Local And Oversea)

√ √

HRM-750-022-WI-001Garis Panduan Prosedur Proses KesPemecahan Kontrak (Breach Of Contract) Penajaan Pengajian Anggota Kerja/BekasAnggota Kerja Akademik Dan TindakanMelalui JHEU, TNB

√ √


DEFINITION

ISO 9001 COPPA EAC

Compliance:Meet the ISO 9001Standard, Policy,Procedure, Guideline,Work Instruction, andetc.

Commendation:Aspects of the provision of theprogramme that are consideredworthy of praise.

Affirmation:Proposed improvements by thedepartment to aspects of theprogramme which the panel believessignificant and welcomes.

Strength:Anything with a ‘wow factor’ of ‘very outstandingnature’ far beyond just satisfying the minimumrequirements with regard to the respective criteriaof Programme Objectives, Programme Outcomes,Academic Curriculum, Student, Academic andSupport Staff, Facilities and Quality ManagementSystem.

NoncomplianceDoesn’t meet the ISO 9001 Standard, Policy, Procedure, Guideline, Work Instruction, and etc.

Area of Concern:Mandatory requirement, which theprogramme must comply with.

Weakness:Clear transgression against the requirements of theManual. Failed to fulfil any of the Eight (8)Qualifying Requirements of the EAC Manual ortransgressed any of the Five (5) Criteria to thepoint of TOTAL COLLAPSE.

Area of Concern:Any shortfall/shortcoming or transgression, but notamounting to a ‘total collapse’, of any of theaccreditation criteria under the Manual.


DEFINITION

ISO 9001 COPPA EAC

Opportunity forImprovement (OFI)Area that isrecommended forimprovement which maybecome noncompliancein the future if no actionis taken.

Recommendation:Proposals by the panel of assessors for improvement of the programme.

Opportunity for Improvement (OFI):Refer to further improvement that an IHL couldconsider despite already having the necessarystrength or having already satisfied the minimumrequirements of the EAC Manual. OFI are ‘good tohave’ or ‘desirables’ recommendations made by theEP for programme Continual Quality Improvement(CQI).


INTEGRATED AUDIT FORM



• Non-conformance Report will use the current system.

• However, the way auditor write out the report will be different based on the changes in new format of integrated audit.


Auditors Competencies

New to

Self-accreditation procedures

Transition to new standard risk based

thinking ISO 9001:2015

TNB Expectations & Requirements

Internalizing of the quality environment culture

Resistance to new changes

ISSUES & CHALLENGES


Part 4: Part 4: Part 4: Part 4: Conducting an integrated audit

Prepare an audit plan, audit check list and sample audit report to audit “provision of education services for undergraduate level”



• Non-conformance Report will use the current system.

• However, the way auditor write out the report will be different based on the changes in new format of integrated audit.