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 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 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 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
Root Cause Analysis
Audit Readiness
• 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 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.
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*Definitions blatantly plagiarized from: http://www.businessdictionary.com/
DQ
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 Readiness
Current POA&M Format
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DQ
MEPRS
Audit Readiness
Let’s Look At What NOT To Do…..
Using what you have learned from the previous slides, can you identify why this is not a good
POA&M?
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DQ
MEPRS
Audit Readiness
Example of a Proper POA&M
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DQ
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 Readiness
Some Examples of Not-So-Useful Comments
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DQ
MEPRS
Audit Readiness
Questions?
* Picture copied from icanhascheezburger.com
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