Chatham-Kent Health Alliance Releases External Audit and Identifies Critical Gaps and Opportunities for Improvement

CHATHAM-KENT: March 22, 2017 – To rebuild and strengthen its governance structure and related operating processes, Chatham-Kent Health Alliance (CKHA) enlisted external auditors to review its internal controls organization-wide and identify areas for improvement. To execute this review CKHA adopted the 2013 COSO Framework – a recognized and proven model to assess control effectiveness at the strategic, operational and functional levels of an organization.
The COSO model defines internal control as “a process, effected by an entity’s board of directors, management and other personnel, designed to provide reasonable assurance of the achievement of objectives in the following categories: effectiveness and efficiency of operations, reliability of financial reporting, compliance with applicable laws and regulations”. COSO is based on 17 principles within 5 control categories, all of which need to be in place to support an effective system of internal control.
“By conducting a review of our internal controls, we can ensure that our environment is appropriate and effective in the reliability of internal and external reporting, compliance with applicable laws, regulations and internal policies, and safeguarding the organization’s resources,” said Ken Deane, President and CEO (Interim).
The audit focused an assessment of CKHA’s core entity-wide corporate controls in the areas of:

• Ethics and Values 
• Governance 
• Human Resources
• General Information Technology (IT)
• Finance 
• Strategic Planning and Budgeting / Internal Reporting 
An examination of corporate-wide policies and practices supporting CKHA’s communication, risk management and project management practices were also included.
“The external audit gives us a solid foundation to build on and ensures we achieve our objectives effectively and efficiently as we continue our organization-wide transformation,” said Lori Marshall, President and CEO. “Adopting the COSO framework solidifies our commitment to operational sustainability, sound stewardship and accountability to our stakeholders and community.”
Over the past six months CKHA has made significant improvements across all COSO principles with an emphasis on rebuilding senior leadership, increasing communication with staff and the community at large, transparency in financial reporting and improving communication with the Board. It is important to note that there are no longer any critical gaps. Among the sound practices identified in supporting these improvements were formal communications to staff, physicians and volunteers emphasizing CKHA’s mission, vision, values, and the importance of the Code of Conduct, the recently launched Whistleblower Hotline,  a new website – – that provides a forum for questions from the public, and significant improvement in “tone at the top” from Senior Leadership through greater transparency, an open-door policy, and more frequent internal communications with staff.
The priority gaps and areas of improvement identified, many of which are in the process of being addressed, include a review to strengthen key corporate policies for completeness such as the Code of Conduct, Conflict of Interest, Disclosure, Procurement, Capital Expenditures, Delegations of Authority and IT. Strengthen Board reporting through standard agenda items, progress reports on major projects, and documentation of approvals and key decisions. Strengthen CEO and management performance assessment process, including documentation and assessment of performance against strategic goals and financial performance. Formalize and implement succession planning and talent development plans, and formalize key performance indicators to enable consistent tracking of progress against objectives. 
For more information and to view the complete findings of the audit, please visit under “Financial” and “Governance.”
To arrange an interview, please contact:
Fannie Vavoulis
Director, Communications 
fvavoulis [at] ckha [dot] on [dot] ca

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