CAP or Corrective Action Plan is a program that consists of a CAP form and instructions that allow you to systematically respond to each major finding (rating of “1” and all minor findings on initial certification audits) and submit them to the SSPC Corporate Certification Program Manager for acceptance. If you have any major/minor findings, the auditor will notify you at the audit out brief and request Corrective Action Reports for each major/minor finding. When that happens, the first step is to review the SSPC form and instructions and use them to:
1. Describe how you corrected the immediate problem. This may also be referred to as the “fix” or “corrective measure” taken. For example, if the auditor finds inspection instruments out of calibration, the immediate fix or corrective measure is to either send the instruments to a qualified lab to have them recalibrated or discard any instrument that is broken and not worth fixing. In short, get the damaged or improperly operating instrument out of service.
2. The second step in the process is to do and document a “root cause analysis.” Simply put, this means “why” the deficiency occurred and your management needs to discuss what broke down in the system that you had previously set up that caused the finding in the first place. Once the “root cause” is determined, the next step is to install a permanent change or “preventive action” in your quality system to prevent the problem from recurring. Using the instrument example above, you might have discovered during the root cause analysis that the smooth operation of this component of your system depended upon one key person. And when that person was unavailable for an extended period of time due to an illness, there was no qualified person trained to perform back-up duties.
3. The third step or corrective action would be to train one or two qualified backup(s) to avoid recurrence of this problem. This might require training an existing staff member or outsourcing the work.
4. The last step in the overall “corrective action plan” would be for management to follow up to ensure that an effective backup plan is in place and working effectively to handle instrument calibrations when the key person is unavailable to direct the process. The entire process is called “Corrective Action.” “Corrective Action” is beneficial as it allows your company to identify problems and mistakes, conduct a detailed root cause analysis, implement corrective action, and install procedures that prevent them from happening again. Recurring problems in a quality system can increase rework, thus cutting into production and job profits. If safety is involved, recurring problems can lead to accidents and injuries. The more you and your organization are willing to recognize problems and address them, the less likely these problems will reoccur. Continually improving your operation allows your organization to operate more efficiently, cost-effectively, and keeps your customers satisfied.
For more information about how to implement a Corrective Action Plan, contact Henry Arato | firstname.lastname@example.org.