MSU OP 5 Procedure for Corrective Action - Maseno University

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