An audit of clinical outcomes and client and referrer satisfaction with a mood and anxiety Disorders unit

Objective To evaluate outcome and client and referrer satisfaction with the service provided by a Mood and Anxiety Disorders Unit (MADU).

Method MADU was a specialized clinical service for the assessment and management of individuals suffering with affective and anxiety disorders. Clients were referred to MADU from a variety of health service providers. A telephone survey of 30 clients and 20 referrers who have used the services of MADU was conducted, investigating outcome satisfaction with the service provided by MADU.

Results Clients and referrers reported a high level of satisfaction with the service provided by MADU. There was a high degree of adherence to treatment recommendations. The mean Patient Global Impression of Improvement (PGI) rating by the clients before the MADU assessment was 2.74 (SD = 1.27). In comparison the mean PGI rating at the time of follow-up was 6.64 (SD = 1.91).

Conclusions Specialist mood disorders units are a useful and potentially cost-effective additional service included as a part of a mental health service.

MAAGs: the next generation. A study of the development of medical audit advisory groups and the arrangements for supporting clinical audit in primary care

Background: MAAGs have, historically, been disparate organisations with a lack of central direction, albeit with the same goal: to develop and support the performance of audit in primary care. This goal has been (and is being) achieved in a number of ways all over the country. In the last two years, MAAGs have witnessed many changes in primary care and are adapting themselves to suit these new arrangements at a local level.

Aim: To formalise our knowledge of where MAAGs are going, how they are getting there and the support they are receiving.

Method: A postal questionnaire to the 104 MAAGs in England and Wales, addressing 6 main issues of relevance to the development of MAAGs and the support they are receiving.

Results: At least two MAAGs have dissolved, leaving a possible total of 102 still in existence. Of these, 76 (74.5%) responded to the survey. The composition of the MAAG committee has changed dramatically since the inception of MAAGs in 1990, and staffing levels appear to have risen substantially. MAAGs appear to be more adequately funded by their health authorities than has previously been reported and many are actively seeking additional sources of funding. There is still large variation in levels of MAAG funding. Furthermore, funding is unrelated to the number of GPs or practices served. Security for MAAG staff appears to have been addressed in many areas, with 84% of MAAGs having at least one member of staff on a permanent employment contract. Many MAAGs are developing rolling programmes in an attempt to eliminate the short-sighted approach to the development of clinical audit that has existed since MAAGs were first set up.

Conclusion: Many MAAGs (with the obvious exception of those that have been dissolved) appear to be thriving without central direction or initiative. It is now evident that we were a little hasty in our concerns for the future of MAAGs beyond April 1996. It would seem that many organisations have taken the situation which arose two years ago as an opportunity to grow and develop in ways that may not have been possible within the confines of the Health Circular.

Internal audit involvement in enterprise risk management

Purpose – The purpose of this paper is to examine the impact of internal auditors’ involvement in enterprise risk management (ERM) on perceptions of their willingness to report a breakdown in risk procedures and whether a strong relationship with the audit committee affects such willingness to report. The study also investigates the use of ERM and the role of internal audit in ERM in Australian private and public sector entities.
Design/methodology/approach – The study uses an experimental design, manipulating the internal auditor’s involvement in ERM and the strength of the relationship between internal audit and the audit committee. Participants are 117 certified internal auditors. The study also gathers descriptive data on the use of ERM.
Findings – The study indicates that a high involvement in ERM impacts the perceptions of internal
auditors’ willingness to report a breakdown in risk procedures to the audit committee. However, a strong relationship with the audit committee does not appear to affect their perceived willingness to report. The study also finds that the majority of organisations have recently adopted ERM. Internal auditors are involved in ERM assurance activities but some also engage in activities that could compromise objectivity.
Research limitations/implications – There are internal and external validity threats associated with the experimental design.
Practical implications – The findings reinforce the need for organisations to adhere to the recommendations of the Institute of Internal Auditors and to ensure that internal auditors do not play an inappropriate role in ERM.
Originality/value – The paper contributes to our understanding of the impact of involvement in ERM on internal audit objectivity and of the current role of internal audit in ERM in Australia.

Accountability structures and management relationships of internal audit : an Australian study

Purpose – The purpose of this study is to examine the accountability structures and the management relationships of internal audit. In particular, related issues such as the predominant internal audit objectives and the related functions, the extent to which internal audit addresses any financial reporting risks and the manner in which internal auditors in Australia perform their tasks, are identified. The study also looks at the extent of compliance with the Institute of Internal Auditors (IIA) Standards.
Design/methodology/approach – Based on a survey of the chief audit executives in Australia, the study identifies the reporting mechanisms, functions and relationships of internal audit, including the contributions made towards good corporate governance. There is, however, some misalignment between the aspirations of internal auditors and their relationships with management.
Findings – While internal audit objectives have been established with a focus on controls, risks and governance, the study has highlighted the fact that there is a lack of correlation between the tasks performed by internal auditors and the important internal audit objectives, with the exception of internal control and risks. The results also suggest that internal auditors have been providing an internal consulting and advisory role in matters concerning IT systems, strategic risks and financial issues. If internal auditors are to proactively contribute to good corporate governance, they need to define how, and in what way, this can be done. In regard to corporate governance processes, the results of the research indicate that issues surrounding internal control, risk assessment and management processes are regarded as the key factors for internal audit to contribute to good corporate governance.
Originality/value – This study complements and contributes to the existing literature in providing insights into the evolving role of the internal audit function in terms of accountabilities and relationships with management. It also provides a valuable insight into how the internal audit profession can build upon its inherent strengths and address any apparent areas of concern. This will assist both the profession and policy makers alike, in better understanding and improving the role of the internal audit process.

Auditor independence : shared meaning between the demand and supply sides of the audit services market?

Purpose – The purpose of the paper is to examine the extent to which there is shared meaning of the concept of auditor independence between the three major groups of parties on the demand and supply sides of the audit services market – auditors, financial report preparers and financial report users.

Design/methodology/approach – The paper utilises the measurement of meaning framework (semantic differential analysis) originally proposed by Osgood et al. in 1957. The framework is used to investigate the extent to which there is shared meaning (agreement in interpretations) of the independence concept, in response to alternative audit engagement case contexts, between key parties to the financial reporting communication process. The study's research data was collected in the period March 2004-May 2005.

Findings – Findings indicate a robust and stable single-factor cognitive structure within which the research participants interpret the connotative meaning of the auditor independence concept. An analysis of the experimental cases finds similarities in connotations (interpretations) of an audit firm's independence for the participant groups for most cases, with the exception of cases involving the joint provision of audit and non-audit (taxation) services.

Research limitations/implications – The usual external validity threat that applies to experimental research generally applies to the study. That is, the results may not be generalisable to settings beyond those examined in the study. An important implication of the study is that it emphasises the continuing problematic nature of the joint provision of audit and non-audit services, even in situations where the non-audit services comprise only traditional taxation services.

Originality/value – The study is the first to examine the concept of auditor independence by means of the Osgood et al. measurement of meaning research framework using, as research participants, the three major groups on the demand and supply sides of the audit services market.

Clinical audit, guidelines and standards : a productive relation for managing clinical practices

This paper contributes to the knowledge about the process of standardisation within the domain of medicine. Standardisation has become an important form of governance and co-ordination, and there is limited empirical knowledge about its nature and consequences (Brunsson et al., 2000). This paper aims to explore the development, circulation and standardisation process of a specific clinical audit programme: the Scottish Hip Fracture Audit. This audit started as a local initiative and now has developed into a sophisticated arena (Sahlin-Andersson, 2000) which provides Scottish hospitals with monthly ‘real-time reports’ outlining their performance against Scottish government targets. The paper argues that the interrelation between clinical audit and evidence-based medicine (EBM) can become a ‘productive relation’ (Mykhalovskiy, 2003), that opens up spaces of intervention, in which the clinical communities engage with processes of change of clinical procedures, and in these spaces, clinicians and managers are in a position to refine clinical practice and service organisation, to reflect upon their own actions and to allow insight into the rationalities of their work (Berg, 1997).

Audit of the Douglas Hocking Research Institute bone bank : ten years of non-irradiated bone graft

Background:  An audit performed in the use of non-irradiated femoral head bone graft at the Geelong Hospital over a 10-year period. While it is thought the non-irradiated bone graft provides a better structural construct there is theoretical increased risk of infection transmission.

Methods:  We performed a retrospective review of prospectively collected data in the use of non-irradiated bone allograft used from the Geelong Hospital Douglas Hosking Research Institute bone bank over a 10-year period. The review was performed using data collected from the bone bank and correlating it with the patient’s medical record. All complications, including infections, related to the use of the allograft were recorded.

Results:  We found that over the 10 years to 2004 that 811 femoral heads were donated, with 555 being used over 362 procedures in 316 patients. We identified a total of nine deep infections, of which seven were in joint replacements. Overall this was a 2.5% deep infection rate, which was lowered to 1.4% if the previously infected joints that were operated on were excluded.

Conclusion:  The use of non-irradiated femoral head bone graft was safe in a regional setting.

Factors affecting capital program performance audit findings

Complex capital programs require specialized management techniques, in order to address the volatility, cost overruns, significant delays in completion, and failures with which such programs are typically associated. The need is greater than ever for careful oversight, especially for programs that expend public monies.

Audit is commonly a statutory or governance requirement on such programs, but traditional performance audit techniques and standards may be insufficient for certain types of programs and industries, providing a mere illusion of oversight adequacy instead of the assurance that is needed. In order to most appropriately define the performance audit scope, phrase the solicitation for services, select the audit team, and provide support to the auditors during the engagement, public and private sector entity auditees need to understand the factors that impact performance audit results and effectiveness. The question becomes one of how performance audit can be improved, and stakeholders satisfied regarding program achievements, accountability for resource use, transparency in operations, and risk management.

The author considered program complexity, governance, project controls, the history and evolution of the audit function, stakeholder expectations, assurance, and obstacles to audit, and used this information in conjunction with data from a large sample of 775 audit reports from complex construction programs, to derive questions and conclusions about performance audit results and effectiveness, and comparisons to expenditure audit results. The ultimate goal was to define key components in the execution of performance audits, based on theconclusions of the analysis, in order to improve performance audit findings and thus their applicability and usefulness.

While this study focused on program performance audit, it was also related to the field of program management. Although the data population was concentrated in the area of construction programs, conclusions from this research may also be applied to other complex, multifaceted or phased activities such as projects and programs in other industries (manufacturing, information technology), and also pursuits such as major event planning, company launch, mergers, and large program implementations or rollouts.

The research results clearly demonstrated that different types of findings were generated by different audit scopes. The author observed that typical audit findings focused on routine procedural, accounting, and controls errors. On average, contract expenditure audits questioned only 2.65% of expenditures, and performance audits of large complex programs questioned only 0.03% of expenditures. The majority (72.56%) of the performance audits in the sample yielded no findings or questioned costs.

There were significant positive correlations between: the number of expenditures tested and the number of qualitative findings, inclusion of construction experts on the audit team and the percentage of expenditures questioned, inclusion of construction experts on the audit team and the number of qualitative findings, broader audit scope and the percentage of expenditures questioned, and broader audit scope and the number of qualitative findings. Of these, auditor expertise and audit scope were the driving factors.

There were significant negative correlations between the application of agreed-upon procedures and the percentage of expenditures questioned, and the application of agreed upon-procedures and the number of qualitative findings. It was determined that the significant negative correlation between the application of audit standards and the number of qualitative findings was due to other factors, such as the application of agreed-upon procedures and the lack of construction experts on the audit team.

Other findings, resulting from review of the data, were unrelated to the research questions yet of considerable importance to industry. An extremely high percentage (81%) of the “performance audits” instead applied a very limited set of agreed-upon-procedures (AUP) in the engagement, According to the American Institute of Certified Public Accountants (CPAs), AUP engagements could not be classified as audits. Thus, it was inappropriate for the accounting firms to apply AUP engagements in lieu of a performance audit, and it was especially egregious for them to state in their report that the engagements were conducted in accordance with audit standards, as AUP engagements and the specific audit standards were by their very nature mutually exclusive.