Environmental Auditing Practice & Charter

The Environmental Quality Management Department (EQM) is responsible for conducting internal environmental compliance audits of all healthcare, academic, research, and operational entities of UK.  This function is authorized through an Environmental Audit Charter from the Executive Vice President for Finance and Administration, the Provost, and the Executive Vice President Health Affairs to the applicable entities of UK.  By routinely monitoring areas against function specific audit protocols using professional web-based resources and based on the Environmental Protection Agency  (EPA) and state regulatory requirements these audits will assist in recognizing:

• Recognizing exemplary practices,
• Identifying requirements to facilitate compliance and
• Achieve potential operational improvements

The process also assists in formulating action plans to address identified opportunities for improvement and tracking the actions to closure.

The audits will be a collaborative effort between EQM and the audited area and adhere to EPA’s Environmental Audit Protocols.  The audits will follow the completion pathway described below:

 

Audit Notification

• Custom audit profile and audit protocol developed using professional commercially available web-based software.
• Issued by EQM Auditor to notify management of the planned audit.
• As an attachment, the planned audit protocol to be used may be included as appropriate.

Audit Plan

• EQM Auditor and department contact collaborate to finalize scope and schedule the on site evaluation.
• Department completes preparation, including document gathering as necessary to facilitate the on-site evaluation.

Opening Meeting

• Meet the persons involved in the audit, answer any questions or concerns, clarify the audit intent, and review the timeline.

Field Work

• Evaluation of operation using the previously provided audit protocol.
• Physical conditions tour.
• Interview of representative personnel to determine the level of involvement and understanding at the operation.

Closing Meeting

• Verbal communication of audit results
• Achieve clarification and consensus regarding accuracy of the preliminary audit results

Preliminary Draft Report

• Collaboration between department contact and auditor to ensure accuracy
• Corrective actions, responsible persons and due dates are developed

Final Draft Report

• Issued by the EQM auditor to the department contact and other applicable parties.

Follow-Up Review

• Department contact will provide updates regarding status of closure of corrective actions
• EQM Auditor will conduct a follow up review at the facility to verify closure of corrective actions.