UNM and Health System Internal Audit Departments Internal Audit Department Orientation Manu Patel, Internal Audit Director Purvi Mody, Executive Director, Compliance and Internal Audit, Health System June 5, 2015

UNM and Health System Internal Audit Departments Audit and Compliance Committee (RPM 1.2, 7.3) A standing committee of the Board of Regents One member should be “financial expert” Meets four or more times a year Follows Open Meetings Act 2

UNM and Health System Internal Audit Departments Audit and Compliance Committee (RPM 7.3) Oversight Responsibilities for University’s: Financial reporting Internal controls Risk management Performance of external financial and internal auditors Compliance with laws and regulations Compliance program Federal, state agencies audits and compliance reviews 3

UNM and Health System Internal Audit Departments Authority of Internal Audit Dept. (IA) (RPM 7.2) Was established to perform a comprehensive internal audit function Has unrestricted access to all functions, records, property, and personnel Obtains the necessary assistance of personnel Communicates with personnel of internal, external, law enforcement agencies, etc. 4

UNM and Health System Internal Audit Departments Independence IA reports functionally to the Audit and Compliance Committee Free from interference in determining the scope of internal auditing Empowered to obtain the information needed IA reports administratively to the University President 5

UNM and Health System Internal Audit Departments Independence (cont.) Health System Internal Audit reports administratively to the Chief Executive Officer and Administrator of Hospital Operations 6

UNM and Health System Internal Audit Departments UNM Internal Audit Reporting Lines 7

Internal Audit UNM Board of Regents HS Internal Audit (Purvi Mody) UNM Main Campus Audit Committee of Each Entity and COO of the Health System (Steve McKernan) UNM Internal Audit Health System Internal Audit UNM Internal Audit (Manu Patel) Health Sciences Center School of Medicine, College of Nursing and Pharmacy Research (Cancer Center and HSC) Branch Campuses, Affiliated entities (Foundation and Lobo Development, etc ) Health System UNM Hospitals and 57 Clinics UNM Cancer Center Clinics UNM Medical Group and 7 clinics UNM SRMC 8

UNM and Health System Internal Audit Departments Report Functionally to the Committee The Committee reviews and approves UNM Internal Audit’s: –Risk based internal audit plan –Budget and resource plan –Work product: audit, consulting reports, etc. –Follow up report on management’s responses to audit recommendations –Health System IA reports functionally to Board of Trustees’ Audit and Compliance Committee 9

UNM and Health System Internal Audit Departments Purpose and Scope of Work Improve the University's operations Determine whether the University's systems of controls, risk management, and governance, are adequate, and functioning properly to ensure: Risks are identified and managed Employees' actions are compliant with policies etc. Resources are acquired economically, used efficiently, and adequately protected, etc. 10

UNM and Health System Internal Audit Departments Investigation of Fraudulent Activity University policy requires Internal Audit to conduct investigations of fraud and employee misconduct if financial Will coordinate investigations of suspected fraudulent activities within the University 11

UNM and Health System Internal Audit Departments Relevant UNM Policies Policy 2200: Whistleblower Protection and Reporting Suspected Misconduct and Retaliation Policy 7205: Dishonest or Fraudulent Activities 12

UNM and Health System Internal Audit Departments Definition of Internal Auditing “… an independent, objective assurance and consulting activity designed to add value and improve an organization's operations. It helps an organization accomplish its objectives by bringing a systematic, disciplined approach to evaluate and improve the effectiveness of risk management, control, and governance processes.” The Institute of Internal Auditors 13

UNM and Health System Internal Audit Departments Assurance Services We provide an independent assessment on governance, risk management, and control processes Examples of assurance engagements: –management and performance –compliance –information technology –special requests –fraud 14

UNM and Health System Internal Audit Departments Types of Assurance Engagements Special Request from senior management or the Board of Regents –may result from concerns about a program, function or account Fraud examination –initiated from irregularities identified during routine audit work, management who find fraud in their organizations, and complaints from various sources including the Hotline 15

UNM and Health System Internal Audit Departments Risk Based Auditing Focus on –risk of occurrences that could prevent the University from achieving its goals –areas with high risk where controls are not in place or are weak Risk based audit plan –developed with input from across the University –based on available man hours –A university-wide 5-year plan is revisited annually 16

UNM and Health System Internal Audit Departments IA Process of Audit Report Management responds to the report with 3 required elements within 10 days Management obtains its EVP’s approval President approves management’s responses Committee reviews and approves Report is made public except exempted information 17

UNM and Health System Internal Audit Departments Standards and Ethics Adhere strictly to the Code of Ethics as established by the Institute of Internal Auditors (IIA) Abide by applicable standards made by IIA and the American Institute of Certified Public Accountants (AICPA) 18

UNM and Health System Internal Audit Departments Quality IA must have a peer review at least once every five years Last quality assessment was approved in March