| 4. In which ways is the initiative creative and innovative?
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This is an initiative within the scope of the internal audit units of the Federal Public Administration, in Brazil, and it is unique, since it proposes an innovative joint action between auditees and auditors in identifying their weaknesses.
The Program does not primarily focus on error detection but rather on management performance, with all the stakeholders involved in the process identifying weaknesses and potential improvements in their work. It also stands out as a simple and inventive way of presenting and accepting the internal audit unit, since the auditor is a facilitator in the measurement [evaluation] process.
Its singularity stems from the fact that its development is based on the adaptation of established tools, such as COSO and COBIT, and on Brazilian auditing and control standards in public administration, which had not yet been accomplished, while encouraging the participation of all institutional levels.
Another point is the improvement of the company's Management environment which consists of the idea that everyone is aware of their share of responsibility and seek better results in serving citizens who need this public service as well as acknowledge that good work depends on everybody's contribution.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Ebserh Brazilian Company of Health Services) is a national company with 100% of its capital belonging to the Brazilian government. It was created in 12/15/2011 to offer free of charge services in medical-hospital and outpatient care, as well as therapeutical and diagnosis support to the community, mainly the vulnerable and the impoverished. It also aims to train individuals in the public health sector (doctors, nurses, nutritionists, physiotherapists, etc.) in all 40 Federal University Hospitals (HUFs) scattered across Brazil.
Ebserh already directly manages 40 health units in the country, 35 out of these being federal university hospitals and 5 maternity hospitals with free assistance to the most vulnerable population groups, raising their official indicators on bed occupancy rates and number of health and medical assistance professionals.
Out of 60 thousand workers that are currently operating in Ebserh’s hospitals network, 20 thousand were hired during Ebserh’s management and are directly responsible for over 15 thousand appointments per day¹ across the network.
The program has already been implemented in 26 out of these 40 hospitals.
According to the Brazilian Ministry of Health’s official indicators, Ebserh’s general and maternity hospitals who are in the program attend around 2 million and 100 thousand patients¹ throughout the country, mostly the socially vulnerable and the underprivileged. These hospitals are considered to be part of the largest network in Brazil of medical assistance and training of public and free of charge health.
Thus, we believe those being directly benefited by the enhancements in the work place environment and by the quality in assistance and teaching are all 60 thousand professionals that work in Ebserh health units, as well as all 6 thousand patients across Brazil per day, out of which 1,1 are women with prenatal, childbirth and postpartum vulnerabilities.¹
¹Official numbers of Ebserh management system on 03/15/2017.
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| 6. How was the strategy implemented and what resources were mobilized?
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This methodology is interesting and stands out because it stands apart from the traditional form of auditing. Instead of performing traditional evaluation activities by comparing a factual situation with models and ideal situations, and then suggesting improvement actions, this methodology suggests quite the opposite. That is, by considering ideal and needed parameters and situations, identified by the manager, said manager will do a self-assessment. Then, after certain period of time and actions identified and performed by his staff, he has his work evaluated, an evaluation of the inherent and residual risks. This methodology won the 3rd CGU Good Practice Competition in the year of 2015.
For its development during the whole year of 2013 and the first semester of 2014, there were professionals from 10 health institutions of Ebserh, as well as 6 auditors, all of them spread across the country, involved in this process from the start. The financial costs are considered basic, once the development with the health professionals was undertaken through profiting from already the scheduled monthly meetings that took place during a specialization course for hospital managing inside the Syrian- Lebanese Hospital dependencies.
From the definition of what they consider the best techniques, the following step involved the technical contribution of the Ebserh’s internal auditing professionals. Considering that they made use of knowledge acquired during their work in Brazil and also in another countries, either at government institutions or in auditing international private companies, cost was diluted in everyday activities at Ebserh's auditing unit.
In August 2014 we performed the first two tests, one in a famously active maternity hospital that deals with deprived population in extreme social risk, including indigents and prostitutes, and the other at the São Luiz University Hospital, in the state of Maranhão. The latter is a large Hospital containing 3,500 employees, which is responsible for providing service to the whole area's deprived population.
After some needed adjustments to tools and methodologies, we came down to 30 statements distributed in 6 axes of management: Strategic Alignment, Compliance, Process Management, Risks Management, Staff Management and Information Management.
Operationally, auditing is responsible for the initial contact with the general and maternity hospital’s governance; the promotion is carried out by the institution communication sector. Then, a preliminary meeting takes place with the whole governance staff from all levels, in order to gain comprehension and involvement from all heads and supervisors.
Applied data collecting forms are handed out. They are segmented by sector, shifts, work time, etc, where there are 30 statements laid out in a Likert scale, distributed into the before mentioned 6 axes of management, with enough space for comments and suggestions. Additionally, interviews focused on work mediations are carried out. At this point, 45% of the employees from the health unit are participating, ranging from 400 to 1800 people per general and maternity hospitals.
After the insertion of all answers that were on the worksheets, the results are presented to the unit health’s staff, who then decides to convene the Committee responsible for discussion and presentation of proposals to the board.
The internal audit and managers were responsible for the development of these techniques. The application was made under the internal audit orientations with the aid of beneficiaries and the community. The community through the Internal Control Committee carries out the proposed solution while the internal audit and the country’s official control bodies are responsible for monitoring. The response to the initial goal is evaluated by official indicators and by the beneficiaries through a research and ombudsman service. The costs, although minimum when taking the results into consideration, were paid by the government.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The initiative began inside the Institution’s Internal Auditing Unit. With the aim to help management by providing useful information to the decision-making process, the internal audit in the 30 Institutions’ affiliates started to meet in videoconferences. They did so with the initial intention of identifying the proper methodology. Due to its nonexistence, the auditors had to create a legal mark for public auditing works inside the government’s health institutions.
Soon, the initiative was accepted by the managers who had never had active internal auditing units and therefore needed information on the source and evolution of their problems so that they could actively correct it, before being held accountable by regulating and inspecting institutions.
In order to the work be successful and reach a minimum rate of reliability of 95%, with an up to 3,5% variation in the answers, the biggest possible number of collaborators had to participate. Currently, this number adds up to 45% each institution’s staff, a total of 12 thousand employees with identified and active participation, including: doctors, managers, health professionals and contracted companies of all levels (catering, cleaning services, etc.) students of several health areas, teachers and patients.
This numbers increases as each new hospital implements its own project. Presently, there are 25 hospitals across the country with projects in progress. We expect that in the first trimester of 2017 5 more hospitals begin the project, which means added 3 to 4 thousand active participation/ opinions on operational areas, operation and assistance to low-income population.
As those responsible for the institution become actively involved, a larger number of people acknowledge the problem and feel themselves part of the solution proposals.
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| 8. What were the most successful outputs and why was the initiative effective?
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Results are incredibly surprising. The highlights are:
Community engagement in the identification and proposal of solutions for the problems found: differently from what seen in some countries, Brazilian public administration has centralizing characteristics and hardly exposes its weaknesses. With the practice, so far, more than 12 thousand people have taken part by identifying issues and expressing their opinions. As a result, this practice won the III Good Practice Competition in 2014 organized by the Comptroller General of the Union (CGU), the highest governmental control body in the Brazilian Executive branch.
More transparency. As more people engage in the decision-making process, more transparency and its consequences, such as a better assistance to the destitute, are seen. To coordinate and directly work on the identified risks and issues, Internal Control Committees are created. This was such an expressive and significant result to the Brazilian population that the institution was once again the winner, this time with internal control results, in the CGU’s IV Good Practices Competition in 2016.
An 620% improvement in the assistance to the lower income population, confirmed through an organized channel to receive reporting and complaints to the institution.
Creation of a Correctional Sector in the institution that deals with the accountability of corruption or issues in assistance to the population.
Incentive to and collaboration in the Evaluation of State-Owned Companies’ Integrity by the Brazilian Federal Control Institution (Avaliação da Integridade de Empresas Estatais pela Instituição Federal de Controle do Brasil) by the Comptroller General of the Union (CGU). Through technical meetings in the first semester of 2015 with CGU’s team, this practice was passed on and used in the auditing methodology and techniques utilized. Currently all state-owned companies in Brazil are being evaluated with this methodology.
Evolution of the evaluation of the governance environment of all hospitals. When the Evaluation Audit on Governance Environment Maturity occurred, 8 to 10 months after the MMAG takes place, evolutions were confirmed in many of the analyzed axis, as it was officially published by the institution. This proves the effectiveness of the implemented solutions and adjustments for the problems found.
This initiative is efficient because it generates a rational standard to asses the operation of a state-owned institution, bringing together, in a simple fashion, recognized control tools such as COSO and COBIT, public audit methodologies and, most importantly, useful information for managers in the decision-making process.
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| 9. What were the main obstacles encountered and how were they overcome?
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I highlight the lack of a primary source of data and references in Brazil as an initial obstacle. There was, indeed, no material on public auditing in Brazilian hospitals. Considering that Brazil has an extensive and rigid legislation on auditing and controlling public spending, the use of sources from other countries presented itself as great difficulty and possibility of error.
Due to the lack of a primary source of data and reference on public auditing in hospitals, any theoretical basis had to be constructed from an important and unprecedented integration between the concepts and norms of public audit, obtained through the Control System Audit Manual Internal, approved by Normative Instruction No. 1, of April 6, 2001, of the Controller General of the Union, with the principles of control, risk and maturity present in instruments internationally recognized as COSO (Committee of Sponsoring Organizations of the Treadway Commission) and COBIT (Control Objectives for Information and related Technology).
Another difficulty was the acceptance of the auditors in public hospitals. Considering that none of the 30 federal university hospitals had an internal audit unit before, and only had interventions by the Federal Audit Court - TCU, there was no history or positive opinion about work done by internal auditors.
The incursion and acceptance of the auditors in public hospitals was the most difficult thing to overcome and it only happened as the results were appearing inside the hospitals.
We noticed that the managers, through WhatsApp groups, had conversations about how the initial acceptance of hospital employees about the practice was less than 10% in the first hospitals against almost 50% in the last ones, which gives us an excellent margin of accuracy, beyond the certainty of being understood and accepted.
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