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Building an internal audit programme

A programme is not a list of audit dates, and the difference is what separates an internal audit that finds things from one that produces a signed form.

Under ISO 19011:2018 an internal audit programme is a managed set of audits with objectives, risk-based scheduling, defined auditor competence and impartiality, methods, records, and its own monitoring and review. The individual audit sits inside it.

Updated · 10 minute read

One three-year audit cycle drawn twice. A rota audits the high-risk process and the stable support process once a year each, the same frequency for everything. A programme weighted by risk audits the high-risk process two or three times a year and the stable support process once in the cycle. A highlighted change trigger, a new supplier, pulls an extra audit into the schedule. Everything is covered in the cycle, not at the same frequency, and the risk basis for each frequency is recorded.A ROTA, AND A PROGRAMMEYEAR 1YEAR 2YEAR 3A ROTAHIGH-RISK PROCESSSTABLE SUPPORTSAME FREQUENCY FOR EVERYTHINGA PROGRAMME, BY RISKHIGH-RISK PROCESSSTABLE SUPPORTAFTER A CHANGENEW SUPPLIEREVERYTHING COVERED IN THE CYCLE, NOT AT THE SAME FREQUENCYTHE RISK BASIS FOR EACH FREQUENCY IS RECORDED
A rota, and a programmeA pattern, not a scheduleSwipe to pan

Programme and audit are not the same word

The programme covers all audits over a defined period, aimed at a stated purpose. An individual audit is one instance against defined criteria and scope. Weak systems have audits and no programme: dates in a calendar, no objectives, no risk basis, no review of whether the audits find anything.

The test is simple. Ask why a particular process is being audited in March rather than September, and why it is being audited twice this year rather than once. If the answer is that it fell there in the rota, there is no programme. If the answer names a risk, a change, a complaint history or a regulatory exposure, there is.

This is also the clause that gets audited. ISO 9001 clause 9.2.2 asks you to plan, establish, implement and maintain an audit programme including frequency, methods, responsibilities, planning requirements and reporting, and to take the importance of the processes concerned into account. A rota satisfies the word planned and none of the rest.

Seven principles, and one of them is newer than the others

Integrity, fair presentation, due professional care, confidentiality, independence and an evidence-based approach, plus the risk-based approach added in the 2018 third edition. The last one runs through programme design, audit objectives, sampling and prioritisation rather than sitting as a heading.

Fair presentation deserves a mention on its own, because it is the one most often quietly broken. It requires audit findings, conclusions and reports to reflect audit activities truthfully and accurately, including significant obstacles encountered. An audit report that omits the fact that the auditor could not get access to the area they came to see is not a fair presentation, and the omission usually happens to be polite rather than to deceive.

What belongs in the programme document

Objectives, scope and boundaries, risks to the programme itself, resources, auditor competence criteria and how competence is evaluated, the schedule, the audit methods, records, and how programme performance is monitored and improved. Ten headings, and most programmes document three.

Risks to the programme are the heading people skip and the one that predicts failure. Auditor availability, access to sites and shifts, independence conflicts in a small team, and over-sampling comfortable low-risk areas are all risks to the programme rather than to the business, and none of them appear anywhere else.

  • Objectives: what the programme is for, beyond satisfying clause 9.2
  • Scope and boundaries: sites, processes, standards, shifts, and what is out
  • Risks and opportunities to the programme itself
  • Resources: auditor days, and who releases people from the day job
  • Auditor competence criteria and the method used to evaluate them
  • The schedule, with the risk basis for each frequency recorded
  • Methods: on site, remote, interview, document review, observation, data analysis
  • Records the programme keeps, and where
  • Monitoring of programme performance
  • Review and improvement of the programme itself

Frequency follows risk, not fairness

Weight the schedule by process criticality, regulatory exposure, nonconformity and complaint history, recent changes in people, equipment, suppliers or software, whether the process is new or outsourced, and time since last audit. Everything in scope is covered over the cycle, not at the same frequency.

A high-risk process may be audited two or three times a year while a stable support process is audited once in the three-year cycle. That is correct, and it is what a risk-based programme looks like when written down. The instinct to audit everything annually because it feels even is the instinct that produces thirty shallow audits instead of eight useful ones.

Changes are the strongest single trigger and the most often missed. A new supplier for a critical component, a line moved, a software system replaced, a key person gone: each of those invalidates part of the evidence base the last audit rested on. Put a change trigger in the programme so the schedule moves when the business does.

Impartiality in a team of one

Auditors shall not audit their own work. In a small organisation that means cross-auditing between functions, borrowing an auditor from another site, or contracting an external auditor for the one function the internal auditor owns. It does not mean auditing yourself carefully.

This is the most common structural failure in a small quality system and it is rarely deliberate. The quality manager runs document control, so the quality manager audits document control, and the audit finds nothing. The finding that gets written at the external audit is against impartiality rather than against document control, which is worse, because it calls the whole programme into question.

Competence is the other half and it needs a record per auditor, not a policy. Education, work experience, auditor training, audit experience, and knowledge of the standard, the processes and the applicable legal requirements. Plus the method used to evaluate all of that, and the result. No certificate is mandated anywhere. A documented criterion and evidence each auditor meets it is what is mandated.

Writing a finding that survives

Three parts, in this order. The requirement: the clause or internal rule and what it demands. The objective evidence: what was seen, where, when, with an identifier. The nonconformity statement: how the evidence fails the requirement. No opinions, no proposed solutions, no names.

Here is the shape, filled in. ISO 9001 clause 7.1.5.2 requires measuring equipment to be calibrated against traceable standards at defined intervals. Pressure gauge PG-014 on Line 2, observed , carried a calibration label expired and no current certificate was available. The requirement for calibration at defined intervals is therefore not met.

The identifier is what makes it survive. PG-014, Line 2, 14 September. Six months later somebody has to verify that the corrective action worked, and without an identifier there is nothing to go back to. A finding that says calibration was found to be poor in the production area cannot be verified by anyone, including the person who wrote it.

Leaving out the proposed solution is deliberate too. The moment an auditor writes what to do, the auditee implements that and nothing else, the root cause is never found, and the auditor has quietly become the consultant for a process they will audit again next year.

Major, minor, and the category that gets abused

A major is the absence or total breakdown of a required process or control, a nonconformity likely to cause failure of the product or service, or several minors against the same requirement showing a systemic breakdown. A minor is a single lapse in a process otherwise defined and implemented.

The third category, opportunity for improvement, is where programmes go to die. An OFI is not a nonconformity and it is not a softer way of raising one. Downgrading a real finding to an OFI because the meeting will be easier is the most common single reason an internal audit programme stops being worth running, and external auditors recognise the pattern immediately: a log full of OFIs and no nonconformities for three years is not a sign of a healthy system.

The rule that keeps it honest: if a requirement is not met, it is a nonconformity, whatever the consequences and whoever owns it. An OFI is for something that meets the requirement and could be better.

Closing the loop, and why timing matters

Require correction, root cause and corrective action with a target date. Then verify effectiveness after enough time has passed for the action to have been tested. A corrective action verified on the day it was implemented has not been verified, it has been witnessed.

The gap between implementation and verification is where the value is. A new form was introduced, the auditor watched it being introduced, and the finding was closed. Whether anybody is still using the form in three months is the actual question, and it can only be answered in three months.

Then feed it back. Recurring root causes are programme intelligence: they say where the schedule should weight next cycle and what belongs in management review. A programme that produces findings and never changes its own schedule in response is missing the monitor, review and improve half of ISO 19011 clause 5, which is the half that makes it a programme.

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Questions from people running the programme

Q01

Is ISO 19011 certifiable?

No, it is guidance. Certification bodies work to ISO/IEC 17021-1. ISO 19011 is what internal and second-party audit programmes should follow, and it is what an external auditor will have in mind when assessing yours.

Q02

How often must internal audits be done?

The standards say at planned intervals and set no frequency. Justify your frequency by risk, cover the whole scope within the certification cycle, and be able to explain why a given process sits where it does in the schedule.

Q03

Can one person audit the whole company?

Only if they never audit their own work, which in practice means one person plus an external or cross-functional auditor for the functions they own. The alternative is a programme that is structurally unable to find anything in the areas the auditor runs.

Q04

Do internal auditors need a certificate?

No mandatory qualification exists. What is required is defined competence criteria and evidence that each auditor meets them. Training helps enormously and it is not the requirement.

Q05

What is the difference between correction and corrective action?

Correction fixes the instance. Corrective action removes the cause so it does not recur. Closing a finding with a correction only is itself one of the most common findings written in this market.

Q06

How many findings should an audit produce?

There is no target, in either direction. A programme that consistently produces zero findings is either auditing the wrong things or not sampling deeply enough, and an auditor who is asked for a quota has stopped being independent.

Q07

Can we outsource internal audit entirely?

You can contract the auditing. You cannot contract out ownership of the programme: the objectives, the risk basis for the schedule and the review of whether it is working stay with you. An outsourced auditor who is handed no programme will build a rota, because that is all they have to go on.

Audit the programme, not just the processes

Once a year, look at your own audit log and ask what it found that you did not already know. If the answer is nothing, the schedule is pointed at the wrong places and that is fixable in an afternoon.

Have the programme reviewed