Becky's Effective Corrective Action System

[Marc]

I liked this message from Becky R. with one comment: I see much of the problem in the failure of folks to understand the 8-D system, or at least it's underpinnings from a Prevent Recurrence (Continuous Improvement) standpoint. Even in companies I see keeping up with corective actions I see root causes such as:

Won’t work, no power, machine down, broken tool, head froze up, contaminated, rough surface, porosity, shortage of parts, rattles, quality problem, worn out, line stopped, not to specification, labour problem, management problem, too much variation, etc.

These are not root causes. Even if you can 'keep up with them' (corrective action requests), seldom are they effective in the sense of Continuous Improvement. Few folks really understand how to effectively do a Corrective Action.

Now - on to Becky:

-----snippo-----

Subject: Re: Q: Effective Corrective Action/Hitchcock/Rezac
Date: Mon, 30 Nov 1998 09:07:43 -0600
From: ISO Standards Discussion

From: Becky Rezac
Subject: RE: Q: Effective Corrective Action/Hitchcock/Rezac

Al-

The CAR system in the company I consult with has evolved over the past
several years, and has, I believe, addressed and "grown past" the
problems you bring up. They are a large company with a full-time CAR
Administrator, but there is no reason that the same concepts can be
scaled down to smaller organizations. Of course, it does take support
from upper management.

Our CARs go through several stages-
1. Initiation-CARs can be written by ANYONE. We happen to have several corrective-action, customer-satisfaction systems in place that are administered by specific organizations, but we have let it be known that CARs are for documenting any problem. Many CARs are documented during audits, but several are generated by simple observation, or to correct what anyone perceives to be a problem. Our CARs can now (recent accomplishment) be initiated over our Intranet, and are to be used by all company sites and regional offices.

2. Assignment-our CAR Administrator assigns a CAR number (actually this is currently being done automatically via the CAR database), and assigns CARs to applicable departments, although he/she may have to contact the Initiator to get more information to make the assignment properly. The Department Manager is sent an email message with the CAR form attached as an RTF file-the Initiator copied. There isn't any filtering being done because there is no need-users know that problems such as "floor is wet", "bathroom lacks supplies", or "I'm not getting my email", etc., are to be called in to our Help Desk instead. To my knowledge the vast majority of CARs initiated are proper and valid.

3. Department First Response-the assigned Department has 2 weeks to respond to the CAR. The response consists of an explanation of what is the "immediate fix" (if necessary), an explanation of any other departments that may need to take action to resolve the CAR, an "owner"-who this CAR is assigned to, and a proposed "fix" date-when they think they will be able to have the problem solved. All of this information is added to the RTF file and sent back to the CAR Administrator. By the way, the Department is "reminded" just before the "Response Due Date", and if they have NOT responded within 5 days after, a message is sent to one level higher. (We used to give the departments 5 working days to respond, but 2 weeks seems to work better and be more reasonable.)

4. Extension Request (if needed)-if the department determines that it cannot meet it's initial proposed "fix" date, it may request an extension. We used to have no rules on this, but currently are allowing only one extension-after all, the department sets the proposed "fix" date itself. The Manager has to approve the extension request.

5. Ready to Close-when the department has implemented whatever changes are necessary, they send back the RTF file with information on the root cause, corrective action taken, preventive action taken, and a list of documents affected by the CAR. (All applicable fields are completed.) If this information has not been submitted before the "proposed fix date", the CAR Administrator sends a reminder. If 5 days after the proposed date either the "ready to close" response or an "extension request" is not received, a message is sent to one level higher.

6. Closure-CARs are not closed until the Initiator says that the actions taken are effective. Any documentation that required updating as a result of the CAR must be updated, released and available before the CAR can close. If the CAR describes something such as a change to an event, that event must have happened so that the changes are apparent, if practical. (We do not keep CARs open several months waiting for events.)

With regards to escalation, as I said, 5 days after a response was due-either the "Department First Response" or the "Ready to Close" information, a message is sent to Management one level higher. Five days later, if necessary, a message is sent one level higher. This repeats until a message is sent to the VP of Quality/Customer Service and the VP of whatever organization was assigned the CAR. Luckily, since we do have the support, this has not happened lately-our CAR system is taken seriously. (A few unlucky souls learned the hard way, but by now everyone has gotten the message!)

When we are receiving repetitive audit findings such as you described below, it is up to the Initiator to make the determination that the fix is not effective. Some of our CAR Initiators are easier than others, but I know that as a CAR Initiator myself I have several times not allowed a CAR to be closed when the department thinks that it has effectively fixed the problem.

--Becky