MSU OP 5 Procedure for Corrective Action - Maseno University

MASENO UNIVERSITYDOCUMENTPROCEDURE FOR CORRECTIVE ACTIONDOC. NO: MSU/MR/OP/05 ISSUE NO: 1DATE OF ISSUE 30/06/08 REV. NO: 1AUTHORIZED BY: VICE-CHANCELLOR ISSUED BY: MANAGEMENT REPRESENTATIVESIGNATURESIGNATURE29

DOCUMENTPROCEDURE FOR CORRECTIVE ACTIONDOC. NO: MSU/MR/OP/05 ISSUE NO: 1DATE OF ISSUE 30/06/08 REV. NO: 10.1 DOCUMENT CHANGESDate Changes Authorized By01/11/10 Redefined the scope01/11/10 Made additional references: ISO 9001:2008,MSU/OP/03, MSU/OP/0401/11/10 Re-structured and re-organized chapter 6 on method.0.2 DOCUMENT DISTRIBUTIONDocuments shall be distributed as follows:S /No01 Master Copy Management representative02 Copy VC03 Copy DVC AA04 Copy DVC A&F05 Copy DVC PRES06 Copy Deans/Directors of Faculties07 Copy Directors08 Copy Heads of Departments30

DOCUMENTPROCEDURE FOR CORRECTIVE ACTIONDOC. NO: MSU/MR/OP/05 ISSUE NO: 1DATE OF ISSUE 30/06/08 REV. NO: 11. PURPOSEThe purpose of this procedure is to ensure that corrective action is taken by Heads of Department and toenhance adherence to QMS standards.2. SCOPEThis procedure covers all processes and procedures in the University.3. REFERENCES3.1 Maseno University Quality Manual3.2 ISO 9001:2008 Quality Management Systems - requirements3.3 MSU/MR/OP/03 – Procedure for Internal Quality Audit3.4 MSU/MR/OP/04 – Procedure for nonconforming Products/Services4. TERMS (DEFINITIONS)4.1 MSU - Maseno University4.2 VC – Vice-Chancellor4.3 DVC - Deputy Vice-Chancellor4.4 HoD - Head of Department4.5 Corrective Action - Action taken to eliminate causes of an identified nonconformity in order toprevent recurrence.4.6 CAR – Corrective Action Request Form4.7 MR – Management Repesentative5. RESPONSIBILITIESThe MR shall ensure the implementation of this procedure together with HoDs who shall oversee thecorrective action process.31

DOCUMENTPROCEDURE FOR CORRECTIVE ACTIONDOC. NO: MSU/MR/OP/05 ISSUE NO: 1DATE OF ISSUE 30/06/08 REV. NO: 16. METHOD6.1 Reviewing of nonconformities6.1.1 Potential nonconformities may be identified during internal (1 st party) audits, supplier (2 nd party)audits or external (3 rd party) audits6.1.2 Internal audit procedure shall be recorded by the internal auditors in the observation forms andsummarised in the audit reports by the MR.6.1.3 Nonconformities identified during supplier audits shall be recorded in the supplier audit reportscompiled by the auditors and submitted to University Management through the MR.6.1.4 Potential nonconformities identified during external audits by external agencies on the UniversityQMS shall be recorded by the auditors and captured in their audit summary reports compiled andcirculated to the University Management for action.6.1.5 Nonconformities identified by University employees during their daily activities in any function shallbe recorded in the departmental corrective action registers.6.1.6 Nonconformities shall also identified by analyzing feedback posted by employees, customers orother stakeholders on suggestion boxes checked weekly by the PR Directorate and Heads ofdepartment and recorded in the suggestion boxes feedback register maintained by the PRdirectorate and departments.6.2 Determining the causes of nonconformities6.2.2 Causes of nonconformities shall be identified by the MR and HoDs from internal audit reports,external audit reports and departmental corrective action registers.6.3 Evaluating the need to ensure that nonconformities do not occur6.3.1 The MR shall examine the corrective action register and identify outstanding CAR’s for follow-up.6.3.2 On or before the date of completion of corrective action, the MR shall follow-up with the HoDs forcorrective action and ensure that corrective action has been effected and all the verificationsignatures have been obtained.6.3.3 The MR and the HoDs shall review during follow-ups, the adequacy of corrective actions taken toaddress nonconformities raised during internal and external audits as contained in the CARs. Whennonconformities have been adequately eliminated by the corrective actions, the MR shall remark assuch in the CAR form and have the CAR closed out.32

DOCUMENTPROCEDURE FOR CORRECTIVE ACTIONDOC. NO: MSU/MR/OP/05 ISSUE NO: 1DATE OF ISSUE 30/06/08 REV. NO: 16.3.4 In situations where corrective action has not been completed or action taken is inadequate, asupplementary CAR shall be raised for the nonconformity and a new corrective action proposed bythe HoD and target date for completion of the corrective action. The nonconformity shall beescalated if found not completed or corrective action inadequate in the supplementary CAR.6.3.5 Corrective actions taken on customer complaints shall be reviewed for adequacy by theimplementing department and other stakeholders before communication to the customer as areport. The corrective actions shall be recorded in the customer complaints register.6.3.6 Corrective actions for nonconformities recorded in the corrective action registers shall be reviewedfor adequacy by the implementing HoD and recorded against each nonconformity in the register.6.4 Determining and implementing action needed6.4.1 The HoDs shall record in the raised CAR, in the customer complaints register or corrective actionregister the actions needed to address the nonconformity and propose a date implementation ofthe corrective action should be completed as the target date. The HoD shall ensure that theproposed and recorded corrective action is appropriate and commensurate with the effects of theencountered and identified nonconformities.6.4.2 The HoDs shall implement the corrective actions within the implementation period as documentedagainst each nonconformity.6.4.3 The MR shall make follow-ups with the HoDs to appraise the progress on corrective actions. Suchfollow up actions shall be recorded as corrective action follow up reports. The MR shall periodicallyupdate the corrective action register and prepare a report of outstanding nonconformities for andcirculate to Management for review and for presentation to Management during ManagementReview Meetings.6.4.4 Corrective actions shall also be reported through corrective action registers as part of employerfeedback, departmental reports and customer complaint registers.6.5 Records of the results of action taken6.5.1 The MR shall make follow-ups with the HoDs to appraise the progress on corrective actions. Suchfollow up actions shall be recorded as corrective action follow up reports. The MR shall periodicallyupdate the corrective action register and prepare a report of outstanding nonconformities for and33

DOCUMENTPROCEDURE FOR CORRECTIVE ACTIONDOC. NO: MSU/MR/OP/05 ISSUE NO: 1DATE OF ISSUE 30/06/08 REV. NO: 1circulate to Management for review and for presentation to Management during ManagementReview Meetings.6.5.2 Corrective actions shall also be reported through corrective action registers as part of employerfeedback, departmental reports and customer complaint registers.6.6 Reviewing the effectiveness of the corrective action taken6.6.1 The MR shall make follow-ups with the HoDs to appraise the progress on corrective actions. Suchfollow up actions shall be recorded as corrective action follow up reports.6.6.2 Corrective actions taken shall be deemed effective only when they prevent recurrence of thenonconformity.6.6.3 Results of corrective actions taken against each identified nonconformity shall be recorded in theCARs during follow ups and in the customer and corrective action registers following completion ofthe actions.34