Corrective Action Process
Automate compliance with corrective action procedures.
Introduction to Corrective and Preventative Actions
When organizations set out to create a set of processes for conducting their work, the focus is on getting things done to meet their customers' requirements, reduce customer complaints, and ensure that the process is efficient and cost-effective.
At the start of a new process, things usually work well, but in time, circumstances change, such as new types of products or services are added, international customers are added, new staff is recruited. When the process no longer aligns with these changing circumstances, then problems creep in. These may include orders not being processed correctly or goods and services not being shipped correctly for specific customers.
When this happens, it is called deviations to the process or non-conformance. We can document, track, and fix these problems with quality management or risk management methodology called the corrective action process.
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Preventative Action Process Definition
Corrective Action Definition
Corrective action is realizing and defining a problem, determining its cause, and taking appropriate measures to prevent it from happening again.
Exact definition from ISO 9001
Corrective action is realizing and defining problems, determining their causes, and taking appropriate measures to prevent their recurrence.
The Corrective Action Process (CAP) then helps to document, create, implement, and verify the actions taken.
Improving Compliance Across the Organization
We apply "corrective action thinking" in our everyday lives but do not formally consider it in that way. A good example is when we find roadworks on a daily commute, after experiencing the frustration of the first journey, we find an alternative route. What we have done is identified a problem and found a solution that meets our needs.
The difference in an organization is that the problem does not just affect one individual. The consequences of not addressing the issue may be much more significant and more costly to the organization, hence having a formal process. The CAP's output is an action plan that sets out the problem, the root cause, and the resolution.
The concept of corrective action grew out of customer audits of suppliers. Problems, also known as non-conformities or deficiencies, would require corrective actions. The manufacturing industry has long provided suppliers with formats for problem-solving. This same approach has been adopted more broadly into the business process area and incorporated explicitly into the BPM methodology.
We should not forget that the CAP is affected when a variant to the process has already occurred. You may ask why the process was set up with known problems in the first place? When developing or reviewing procedures, the objective is always to consider all the potential scenarios for possible deviations and incorporate them into the process. However, given the pace of change, it is a given that change in business circumstances will lead to a deviance from the established process.
Problem Solving and Root Cause Analysis
When it comes to problem-solving and the CAP, there are a few other techniques used in various circumstances or specific industries. These techniques include:
- PDCA. Plan, Do, Check, Act. An iterative management review method is used in business for the control and continuous improvement of processes and products.
- DMAIC. Define, Measure, Analyse, Improve, Control. A data-driven improvement cycle is used for improving, optimizing, and stabilizing business processes and designs.
- 8D. A problem-solving methodology designed to find the root cause of a problem, based on the ISO 9001 technique.
These techniques complement the corrective actions process.
What are the steps in the Corrective Action Process?
There are several variants for applying corrective actions to problem-solving, but essentially, they all follow a common approach. The most popular of these is formalized under the ISO 9001 quality management system. This system is detailed below.
ISO 9001 based: Seven-Step Corrective Action Process:
- Define the problem. Describe the problem. Make sure the problem is, in fact, a real problem and not a perceived problem. Explain the who, what, when, where, and why. Describe the expected outcome and how the issue can be resolved.
- Define the scope. Make sure you understand how big the problem to be addressed is. Give context to the size of the problem. Is it happening every day? Does it happen only for a particular product or transaction or customer, etc.?
- Containment Actions. Make a short-term fix to stop the problem while searching for the ultimate cause and fix. This is about immediate checks or stop-gap measures that will catch the issue again if it recurs while you are finding the root cause.
- Identify the Root Cause. Identifying the root cause is not always easy. There are specific root cause analysis techniques available to assist with this. The objective is to find the underlying cause and not just the perceived problem. It's like a doctor's diagnosis when the patient is complaining of tummy pain, but the doctor diagnosis it to be something specific such as diverticulitis.
- Plan a Corrective Action. Create measurable, achievable solutions with realistic deadlines that focus on the root cause. It needs to include the necessary steps to eliminate the root cause. Depending on the size problem, it may require cost and return on investment analysis, with formal management approval to proceed.
- Implement the Corrective Action. Implement your actions and manage those actions to completion. It could be as simple as making changes to the software or changes in the database. It could be an investment in new equipment in a manufacturing environment because the old equipment is no longer capable of meeting tolerance requirements.
- Follow up to make sure the Plan worked. Document and close out the process with a debrief to determine what was done and inform the team of the changes. Give sufficient time to ensure that the problem does not manifest again. Capture any lessons learned. Finally, ensure record keeping has been done at an adequate level of detail.
As highlighted, there are some variants of these steps (refinements to suit specific industries or organizations. The steps may be a simple list or built into sophisticated software solutions. Like all tools, the value is in using them effectively. Simple tools in a craftsman's hand are better than complex software-based solutions that are not fully understood.
If your organization is not using this methodology, then guidelines and checklists can be tailored to a company-specific format for the process when someone makes a corrective action request.
Typical Example Format of Corrective Action Plan
A popular alternative to the corrective action steps is the 8D Method for problem-solving. This was initially developed by the US Defence Department but was tailored for the automotive industry by Ford. The steps for this are shown in the diagram below:
Another term you may come across as synonymous with the correction process is Corrective and Preventive Action or CAPA.
A typical example format of Corrective Action Plan is given below:
A popular alternative to the corrective action steps is the 8D Method for problem-solving. This was initially developed by the US Defence Department but was tailored for the automotive industry by Ford. The steps for this are shown in the diagram below:
Another term you may come across as synonymous with the correction process is Corrective and Preventive Action or CAPA.
Examples of Corrective Action Process
There are numerous examples of corrective actions in various industrial and business applications. These range from:
- Major incidents. Global disasters such as the Deepwater Horizon incident in 2010, when 11 workers died, 17 were injured, and 60,000 barrels of oil spilled into the sea. The identified cause was the malfunctioning of heavy blades some 20,00 feet underwater. A CAP would have been applied to this incident and all such significant incidents. In this case, the corrective actions have led to changes in design and maintenance processes for similar oil & gas installations globally.
- Deviations from company policy. In HR terms, when an employee breaks a company policy or procedure, then they may be reprimanded after such an action. A good example is an employee taking time off work without any notice. In some instances, the deviation may call for a policy change.
- Calibration of tools. In the manufacturing industry, instruments are regularly re-calibrated to ensure they measure within set tolerance bands.
- Software fixes. Software applications where the data or the program logic provides erroneous output. Action is taken to identify and remedy the problem.
- Human error or lack of training. Incorrect input to business applications due to human error. This may be a genuine mistake or lack of proper training. Action is taken to provide additional training.
- Equipment/software controls. Triggers and alerts on equipment or built into software when a parameter falls outside of a tolerance level. A good example is when an alarm sets off on equipment because the temperature exceeds pre-set limits.
- Non-adherence to a process/procedure. Not following the set process or procedure when completing a task. How many times have we assembled a piece of furniture from a flat-pack and found ourselves so frustrated because we did not carefully follow the instructions?
Systems for Automating and Tracking Corrective Actions
Summary
A corrective action process is a quality management methodology that allows for formal documentation and assessment of industry and business problems.
We recognize that the corrective action process provides a formal documented means of problem-solving. However, we should remember that solid, lasting corrective actions involve more than filling out a template but require disciplined, practical application of the process.
Finally, let us remember that this methodology helps, but this may be costly after the event has occurred in some circumstances. Think of the major incidents and other safety applications and the potential of something going wrong. So, when developing solutions, whether they may be equipment or process-related, we should endeavor to apply a preventive approach (get it right the first time) and avoid using the corrective actions process.
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