Operating Authority Accreditation: How to Respond to Audit Findings
This document outlines four items that should be addressed when preparing Corrective Action Responses to the audit findings.
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Obtaining third-party accreditation of your Operating Authority demonstrates that the Quality Management System (QMS) for your drinking water system meets the requirements of the Drinking Water Quality Management Standard (DWQMS).
The purpose of your QMS is to establish a framework for continual improvement. It is not only focused on the quality of the drinking water you produce, but also on the processes you put in place to ensure this quality. The DWQMS establishes the minimum requirements for your QMS.
On-site and system audits are essential tools for measuring the effectiveness of your QMS. Audit findings will indicate areas where your QMS meets the requirements of the DWQMS (conformance) or doesn’t meet the requirements of the DWQMS (non-conformance). Often, opportunities for continual improvement of your QMS will also be identified.
A non-conformance indicates that your QMS needs to be improved to meet an element (or elements) of the DWQMS, and the third-party accreditation body will outline the specific details of the non-conformance in a Corrective Action Request. You should prepare a Corrective Action Response to document the corrective actions that have been taken to address the non-conformance, and submit it to the third-party accreditation body within the timeframe specified on the Corrective Action Request.
The actions you take to address a non-conformance should be intended to not only fix the problem, but also to modify your QMS so that the process which caused the non-conformance is reviewed to prevent the problem from occurring again. When documenting your corrective actions, you should provide evidence that the problem was recognized, corrected, and that proper controls were installed to make sure that it does not happen again. The following four items should be addressed when preparing your Corrective Action Response to the audit findings.
Immediate short term action (1.0)
Immediate actions are necessary to contain the problem and prevent it from impacting an internal or external customer. It is important to clearly identify what the problem is, where/when the problem occurred, how large the problem is and what areas / people / processes the problem impacts. Sometimes termed remedial actions, these actions will typically deal with the immediate issue at hand.
If a gauge used for measurement has not been calibrated, the remedial action would be to calibrate the gauge.
If it has been identified that a staff member has an out-of-date training record, the remedial actions would be to schedule training for the staff member, to grant the staff member time to complete the scheduled training, and to update the training record for the staff member.
Root Cause (2.0)
A finding of non-conformance is often the symptom of an underlying problem. In answering the question “why did this go wrong?”, the root cause of the problem may be found and addressed. Looking deeper into your QMS and implementing effective correction action(s) will reduce the potential for future non-conformances.
As an analytical tool, Root Cause Analysis is an essential way to perform a comprehensive, system-wide review of significant problems, as well as the events and factors leading to them. Beyond simply re-stating the non-conformance finding, it is important that you fully assess your non-conformance and clearly define the root cause(s).
If a gauge used for measurement has not been calibrated, an issue may be identified with the procedures in place for ensuring that installed equipment is properly tested and calibrated before being put into service.
If it has been identified that a staff member has an out-of-date training record, an issue may be identified in how training information is tracked or maintained.
Corrective Action (3.0)
Once you’ve identified the cause of the problem, a corrective action (or actions) should be identified to prevent future occurrences of the same problem. The action(s) should be tested to ensure that the desired result is being maintained and that there are no undesirable side effects. Your goal should be to make your processes ‘mistake proof’. Where a corrective action cannot be immediately implemented, it is important that you establish an action plan and that you set realistic target dates for the action(s) to be completed.
If a gauge used for measurement has not been calibrated, the procedures, training or instruction manuals may need to be updated to ensure that testing and calibration is undertaken as part of installation or maintenance of all gauges.
If it has been identified that a staff member has an out-of-date training record, a new process for keeping track of training information may need to be developed to ensure that training records are kept upto- date.
It is important that you demonstrate the actions that have been taken to address the non-conformance. Evidence can take many forms, but will include documentation prepared or actions undertaken to address the non-conformance (such updated policies, procedures, processes, etc.). A copy of any evidence should be included in the Corrective Action Response that you provide to the third party accreditation body.
If a gauge used for measurement has not been calibrated, a copy of the updated procedures manual may be included, along with an outline of the changes made and the rationale behind the changes.
If it has been identified that a staff member has an out-of-date training record, a copy of the updated training record may be included, along with an outline of the process(es) established to keep the training records up-to-date.
Simplified Workflow for Preparing a Corrective Action Record