The Elsmar Cove Wiki More Free Files The Elsmar Cove Forums Discussion Thread Index Post Attachments Listing Failure Modes Services and Solutions to Problems Elsmar cove Forums Main Page Elsmar Cove Home Page

View Full Version : Failure to Close Out an Internal Audit Finding


SteelWoman
30th August 2001, 06:26 PM
I have a strange issue/question... I recently did a special audit of one of our dept's because the mgmt. of that dept isn't known for his "follow through" abilities and I was leery of how well his dept. was conforming to his procedures. The audit resulted in 10 findings, one of them "major." The dept. mgr was given nearly 2 months to resolve the findings/fix the problems, but on a scheduled re-check this week it was REAL clear he had not done what was required. I'm concerned about what to do next, having never been in this situation before (!) and also concerned about it's potential impact during our next surveillance audit. I have ZERO management support for disciplining or removing this dept. manager... the suggestion so far has been to just give him ANOTHER deadline, but I have no confidence that will do it. I know I'll need to write up an additional finding about his failure to meet the deadlines, but then what? Any thoughts/suggestions?

E Wall
30th August 2001, 08:14 PM
I'm not sure how you could possibly close out the audit finding if the problems still exists. IMHO that should never be allowed to happen.

I've had similar experiences and if you want to help your system...document! document! document! that you are doing everything possible (and keep communicating/updating both the supervisor and the manager). Try to work with the person responsible...sit down together and make a plan (if possible). Make sure the issue is brought up at Mgmt Rev. If you still get no help, wait until your surveillance audit.

Our problem was they were taking waaaaay to long to fix very *simple* things (some very low quality impact - others high). Some folks I was able to 'partner with' so to speak and helped guide them through taking 'correct' steps to resolve the problem in a timely manner, but that didn't work with all. Finally I sent weekly open RCA logs to all involved (originator/recipient) and both the QA Manager and the Plant Manager. Brought it up and pressed for a resolution plan from the plant mgr at the next Mgmt Rev mtg (really need to take on that pit bull persona in there). Of course things continued as they were. Surveillance audit time rolls around. during the review the auditor wanted to know what steps had been taken to have the open items addressed and i was able to show him all the documentation, including the mgmt rev mtg minutes - where the Plant mgr made a bold "Get it done by X or else!" and wanted to know what he did when his deadline passed. He said he spoke with the supervisor and let him know "that it needs to be done" but was still aware it was open. He got a very polite (and it sooo helps having info come from outside the organization sometimes) "I'm dissapointed to see that the system isn't being supported as stronlgy as in the past" and then the auditor wrote up a NCN. Since then we've overhauled the process (literally...step-by-step, paint by number type instructions including form with #'s that matched instruction sheet) made set timelines depending on quality impact, and every Friday I still issue out the weekly 'RCA Open Log'.

Marc
31st August 2001, 07:24 AM
A 'Key' here is ensuring your corrective action system has a defined escalation path. If it finally reaches management review and they don't do anything, you've done your job. Let the registrar auditors take it from there.

goose
31st August 2001, 09:25 AM
Following Marc's comments we follow the escalation path.

If no response (at least a plan) submitted within 60 days report is issued to monthly Quality Steering Comittee chaired by QA and Plant Manager. Usually this is is effective in getting response for root cause and corrective action.

We have sent a few pesky issues to Quarterly Management Reviews. If items not resolved it's a "hit against Management Review.

Our Registrar auditors like this approach of the Internal Audits being proactive.

SteelWoman
31st August 2001, 09:31 AM
Good replies - thanks! Actually I am well known for my "bulldog" tendencies, and also for my documentation... I have hard copies of every email I've sent (which are MULTIPLE) regarding this problem. Today is the actual deadline for him to have finished these items, and I have been babysitting him for 2 months... it is very clear to all involved that the ONLY way these will get closed is to literally DO them myselves, which would involve me doing the guy's managerial job FOR him.. .which frankly I just don't have the TIME to do. So I think today's additional finding will go against upper management, not this dept. per se, for their failure to support the quality system's continued effectiveness. That will, hopefully, get the attention of the uppermost brass. We'll see..... I've already warned my managers that this places our certification in possible jeopardy for a major non-con at our next surveillance audit... wait and see, I guess, at this point.

THANKS all!

SteelMaiden
31st August 2001, 10:23 AM
As stated in the earlier posts....sometimes you just have to do what you have to do. Document, document and document every point of contact that you have had with this dept. about the nonconformances. Explain to them (and document it) that if they do not meet the deadlines, the registrar will find it and issue a BIG finding, perhaps even pull your certification.
If your registrar is a good partner to you they should be able to sit your managers down and "lecture" them if it comes up at your surveillance.

Good luck!

Raffy
11th September 2001, 07:08 AM
Hi,
As Kevin Mader always say, Document, document and document. We often ask how do we close an audit. After audit, there must be a follow-up audit, to verify the effectiveness of the corrective action the concerned department had taken. During that time, if you found out that the corrective action is indeed effective. Then, its time for you to close the said audit. That is, if you have a provision on your form whether the audit would be closed or not.
Hope this helps,
Raffy

Jim Biz
11th September 2001, 09:33 AM
I have a thought on this that might be worth pondering --

In our system - we have an esclation path somewhat as Marc has described - we do an audit - then schedule a follow-up - (usually 30 days) close or determine that a secondary follow-up will be needed.

At the time of the second follow-up (60 - 90 days depending upon the complexity of the issue) seldom does the problem/issue exist in it's origional form - a "partial" implementation or a change in practices can muddy the waters so to speak...

At that point we have "closed the origional finding" & re-issued corrective action updating the planned steps to address "what is left - to clear up the matter.

Given the above example we have closed the origonal finding - without complete effective actions but brought the remainder of the issue back to the top of the list.

Regards
Jim

SteelWoman
11th September 2001, 10:00 AM
Good responses all around... to update you, the original findings were NOT closed out due to uncooperative dept manager... I extended the deadlines at the request of MY manager (who also manages the problematic manager), and the guy managed to come in under the wire (barely) with some semblance of resolutions. I'm going to attempt to confirm effectiveness this week. But I have, to cover everything, printed out a BOOK of emails about the problems I've had here, and done 99% of my communications with the dept manager only by email so I have documentation. I DO plan to enlist the help of my registrar's auditor when he is here in a few months, and ask him to sit down with my management team about it. I'll probably get in hot water for doing that (one of my manager's says "it won't be a problem unless you make it a problem!") - but for my own integrity and, more importantly, the integrity of this quality system, I need to get the message across (with the help of the registrar) that this is serious stuff... not to be trivialized as, "Oh well... the guy sure tried hard, didn't he."

Thanks for your postings... very helpful, and I particularly liked the suggestion of involving the registrar, if only for a talk with my management team. Our registrar is quite cooperative with such things and I do think that will be effective.

Al Dyer
13th September 2001, 07:27 PM
SteelWoman,

Stick to your guns with your morals and attitude, reputation is the best thing you can have in our career choices.

I once did this when I issued a corrective action to the Vice-President for not holding monthly management meetings. I kept documentation and informed my boss, the General Manager, of the lack of response. He said to make a decision and he would back me up.

After about 3 requests for at least a response I let the subject go and informed the G.M. and gave him a "copy" of all my documentation.

During the surv. audit it came time for management review. I asked the V.P. if he would like to sit in with him and the auditor. As we had two auditors he said no Al, you can go with the other auditor.

After about an hour the lead auditor and I met for a time out. He was laughing so hard I thought he was going to have a stroke.

The V.P. had hand written meeting minutes with no sign-ins or no outcomes, and he had mis-dated them and forgot we had a formal sign-in sheet, agenda, and outcome measurements.

Although he could have written me up under 4.17, he decided to give a major to the V.P. for management review.

Of course as the M.R. I had to sign-off on the write-ups and the V.P. went ballistic.

I did have a good G.M. who stood behind me and backed up my actions, he threatened to fire the both of us. We lasted another two years going through the same crap and the company is now a proud holder of a QS-9000 certificate from Perry Johnson.:D

Alan Greatbatch
2nd November 2001, 11:27 AM
I agree with Jim, planned follow-ups, although I would not leave it 30days. I believe that the longer the NC is left the less likely it is to get closed. I do weekly follow-ups after internal audits until all NCs and CAs are complete. Monthly reports aways copied to the General Manager with length of time that NCs have been open. You can put a metric on length of time to closure of NCs and CAs to monitor improvement of the Quality System. Also I have been known to resort to public humiliation of the offending departmental Manager in front of his superiors, if he is not doing his job then they are not doing theirs. If you do not bring it to their attention then you are not doing yours.

Good luck,

gpainter
2nd November 2001, 12:12 PM
Document what you are doing. I have in one instance issued another CAR to the head of CA for failure to close within a reasonable time. You may want to change your SP to give a time frame for reply and closure. Had this not corrected the problem then a CAR would have went to the ISO rep. then the President. From what you say you have no management commitment. In narrowing down the root cause, I would issue a CAR to the President. I have heard of an instance where a registrar had found no commitment and suspended the registration,although I have not confirmed this. Tell him anyway!!!:p

Unregistered
19th December 2001, 12:18 PM
like any process failure it might be worthwhile to investigate why your internal audit corrective action process is failing.

Could it be that you have issued too many trivial findings. You stated 10 findings of a minor nature. If they are minor i.e. are not direct non-compliances to the standard, or not seen to directly contribute to customer complaints then why raise them in the first place.

I would suggest you look at your own auditing technique and process. Audit findings reported for corrective action need to be seen by the actioner as significant. Either they are not or you have failed to get the siginificance across. Minor document corrections should really be undertaken as part of the auditing process, and not reported for corrective action.

Its often a good technique to align your audit findings with what the department sees itself as its most important issue - make them real and concurrent with the objectives of the business.

Raffy
1st January 2002, 11:45 PM
Originally quoted by gpainter:
".....another CAR to the head of CA for failure to close within a reasonable time."

What does a reasonable time really means? What is the exact time or date a reasonable date I would write on my specs? 7 days? 30 days? 45 days? any comment on this.

I'm still confused :confused: in identifying the exact time that I would put on my specs regarding planned follow-ups?

Again, thanks in advance.
Happy New Year to All.

Raffy

tfish
2nd January 2002, 05:50 PM
You should give them at least 2 weeks to come up with a viable corrective action plan. Within the plan, they should be required to state when the plan will be complete.

After that date the CAR can be verified. I don't think another audit is necessary, simply document how you will verify completion and check effectiveness, then do it!

If the culprit has not completed the plan, pass it back to him with a new due date and copy his (and your) boss.

Tom from Clayton
28th January 2002, 06:12 PM
We usually try to keep it simple. Whenever someone is not responding as soon as they should we "invite" them to our Quality Board meeting and they can describe to the Board (and company) President why they are unable to meet their agreed upon schedule.

We started doing this when we noticed the Presidents staff members were the ones most frequently ignoring their schedules. Obviously this won't work with a larger company but a variation of the theme probably will.


Tom

SteelWoman
28th January 2002, 06:21 PM
OHHHHHH, I LIKE that a LOT!! What a great method! Nothing like a little public humiliation to get the job done! Thanks!

By the way, to update this post... the individual involved no longer has his job as mgr of that department! :bigwave: :bigwave:

Claes Gefvenberg
22nd February 2002, 08:03 AM
Well SteelWoman...

I share your problem and I try to solve it more or less in the same way as you do: Documentation and well.... nagging I guess.

My way of doing the nagging is:

I allow auditees 2 weeks to come up with a deadline and a suggested action.

All our internal audit documentation is assembled in a database application, and when anything passes a deadline without my getting word about any action it's automatically published on our intranet. ( Of course I tell people about looming deadlines and sometimes adjust deadlines acc to agreement - No need to be nasty about it ).

Another thing to consider is to set the audit interval according to results. If I get poor results in an audit or notice that deadlines are not kept, I simply audit that function more often.

Thus, good result in audits and meeting deadlines will keep me off peoples backs. That serves as a bit of a reward to the people who do their stuff right and allows me to concentrate on problem areas.

/Claes

Jamie
22nd February 2002, 10:46 AM
You know this thread has made me realize something I need to do. You guys have talked about follow up audits. The way we used to cover follow up techniques was to simply review all previous findings on a department at each audit. Well, with this said, I have to implement another method. Given, I'm no longer auditing by department, I'm doing it by process. Thanks for the reminder guys!

E Wall what does IMHO stand for? I've seen this used quite a bit throughout this forum and have yet figured it out.

Jamie

D.Scott
22nd February 2002, 02:02 PM
But I have seen it used many ways here at the cove.

1) When it is accompanied by a red face it usually means "I Made Horrible Oversights"

2) After an aruement it could mean "I Might Have Offended"

3) If you have just been audited it might mean "I Must Have Objectives"

4) What I think it really means is "If Men Had Ovaries"

That is all of course In My Humble Opinion as I would never second guess what anyone here says. :ko:

Dave

E Wall
25th February 2002, 08:27 AM
Jaime it looks like Dave covered it pretty well...I especially like #4!:biglaugh: !

When used I apply the "In My Humble Opinion" as the meaning.