Failure to Close Out an Internal Audit Finding

[SteelWoman]

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]

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]

Escalation Path

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]

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]

thanks

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]

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]

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]

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]

Closing out

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]

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.