cqi wessex oct13 ncr training presentation

8/16/2019 CQI Wessex Oct13 NCR Training Presentation

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Non-conformance Reporting

Jim Kirk FCQI CQP

Quality Manager



2

Annex 24



HA NetworkMap

3



HA Area 4 Map

4



What is an NCR?

5

What isn’t an NCR?

•

Trivia• A tool to “get your owna!k"

• #ome o$y%& o'inion a& to&omet(ing going wrong w(enit i& not a!tually a

re)uirement

• A re'ort i&&ue$ w(en a 'ro$u!t* 'ro!e&&or 'ro!e$ure $oe& not !om'ly wit( t(e&et &tan$ar$& +or a 'ro$u!t* 'ro!e&& or'ro!e$ure un$er in&'e!tion• An ,C- i& any &igni.!ant $e.!ien!y• A mean& o+ tra!king a!tion&• A tool to 'ut rig(t t(ing& t(at are goingwrong•

A mean& o+ &to''ing re'eate$ error&• ,C-%& are u&e$ to re!or$ .n$ing& +rominternal an$ e/ternal au$it& t(at re)uirea$$re&&ing• ,C-%& are u&ually rai&e$ +rom wit(in a'ro!e&& team relating to t(eir in'ut&re!eive$ a& out'ut&• A!!umulating $ata +rom a!ro&& t(eorgani&ation an$ re'orting in a !on&i&tentway will ena le you to i$enti+y non0!on+orman!e tren$& e+ore t(ey &eriou&lya1e!t t(e u&ine&&



6

There is aroce!"re

#or Non-conformance$Area 4 Area 4 o!ument Centre Pro!e$ure o!ument&

http://portal.bbmmjv.com/

http://portal.bbmmjv.com/A4Documents

http://portal.bbmmjv.com/A4Documents/Procedures/Forms/AllItems.aspx?View=%7BEE28A527-FE80-47BE-A5D0-879D1E8EBF76%7D&FilterField1=ReportOwner&FilterValue1=Barry%20Topham






%n-&ine NCR '(stem



Raising NCR’s

Cop( from one of these

6 Co'y +rom t(e 'ro!e&&*'ro!e$ure* +orm* tem'lateor ot(er $o!ument* t(ein&tru!tion a& to w(atnee$& to e $one

2 #tate w(at i& wrong an$(ow it $oe&n%t mat!( w(ati& re)uire$

3 I+ you !annot .n$ t(ewritten re)uirement* a&kyour&el+ i+ t(i& i& really anon0!on+orman!e7

F o r m

P r o ! e & &

T e m ' l a t e

8 t ( e r

4 o ! u m e n

t

9 u i $ a n ! e

A!tivity:

To the Acti)it( *ox on the NCR form



arts 2 +,

;

Fi/ t(e

'ro lem• Com'lete t(e+orm !orre!tly• #ign t(e +orm• -e0$raw t(e A&0

uilt•

Clo&e t(e&!(eme• Provi$e t(emi&&ing $o!ument

A&k t(e 5 w(y)ue&tion&• <(y $i$n%t (e $o it7• <(y $i$n%t (e know(e wa& &u''o&e$ to

$o it• <(y wa&n%t (etraine$• <(y wa&n%t t(ere)uirement &'e!i.e$• <(y wa&n%t t(ere

enoug( re&our!e to$o t(e work

=nter t(e root !au&e a+ter an&wering all t(e&e )ue&tion&

>aving worke$ out t(e root !au&e* t(e a!tion to 'revent re!urren!e i& o vio

=nter a reali&ti! $ate

=nter a reali&ti! $ate

e!i$e w(o t(e !orre!t 'er&on i& an$ speak to him her

e!i$e w(o t(e !orre!t 'er&on i& an$ speak to him her

N./. 0"a&it( Managementoints awar!e! if the working

!a( 1 !ea!&ine misse! - from

N./. The Action %wner sho"&!ha)e !isc"sse! with theactionee *efore appro)a&. t is



/' N '% 566782669

-e!or$& o+ t(e au$it& an$ t(eir re&ult& &(all e maintaine$?&ee 4 2 4@

T(e management re&'on&i le +or t(e area eing au$ite$ &(allen&ure t(at any ne!e&&ary !orre!tion& an$ !orre!tivea!tion& are taken wit(out un$ue $elay to eliminate$ete!te$ non!on+ormitie& an$ t(eir !au&e&

6



/' N '% 566782669

9.:.2 Correcti)e action T(e organiBation &(all take a!tion to eliminate t(e !au&e& o+ non!on+ormitie&

in or$er to 'revent re!urren!e

Corre!tive a!tion& &(all e a''ro'riate to t(e e1e!t& o+ t(e non!on+ormitie&en!ountere$

A $o!umente$ 'ro!e$ure &(all e e&ta li&(e$ to $e.ne re)uirement& +ora@ reviewing non!on+ormitie& ?in!lu$ing !u&tomer !om'laint&@*

@ $etermining t(e !au&e& o+ non!on+ormitie&*

!@ evaluating t(e nee$ +or a!tion to en&ure t(at non!on+ormitie& $o not re!ur*

$@ $etermining an$ im'lementing a!tion nee$e$*

e@ re!or$& o+ t(e re&ult& o+ a!tion taken ?&ee 4 2 4@* an$

+@ reviewing t(e e1e!tivene&& o+ t(e !orre!tive a!tion taken

66



/' N '% 566782669

9.:., re)enti)e action T(e organiBation &(all $etermine a!tion to eliminate t(e !au&e& o+

'otential non!on+ormitie& in or$er to 'revent t(eir o!!urren!ePreventive a!tion& &(all e a''ro'riate to t(e e1e!t& o+ t(e 'otential'ro lem&

A $o!umente$ 'ro!e$ure &(all e e&ta li&(e$ to $e.ne re)uirement& +ora@ $etermining 'otential non!on+ormitie& an$ t(eir !au&e&*

@ evaluating t(e nee$ +or a!tion to 'revent o!!urren!e o+non!on+ormitie&*

!@ $etermining an$ im'lementing a!tion nee$e$*

$@ re!or$& o+ re&ult& o+ a!tion taken ?&ee 4 2 4@* an$

e@ reviewing t(e e1e!tivene&& o+ t(e 'reventive a!tion taken

62



There is aroce!"re for

Correcti)e Action$

63

Area 4 Area 4 o!ument Centre Pro!e$ure o!ument&









/en;amin #rank&in<s :-Wh( Ana&(sis

For want o+ a nail a &(oe wa& lo&t*+or want o+ a &(oe a (or&e wa& lo&t*

+or want o+ a (or&e a ri$er wa& lo&t*

+or want o+ a ri$er an army wa& lo&t*

+or want o+ an army a attle wa& lo&t*

+or want o+ a attle t(e war wa& lo&t*

+or want o+ t(e war t(e king$om wa& lo&t*

An! a&& for the want of a &itt&ehorseshoe nai&.



: Wh( 0"estions

6 <(y wa& t(e King$om lo&t7

e!au&e t(e war wa& lo&t2 <(y wa& t(e war lo&t7

e!au&e t(e attle wa& lo&t3 <(y wa& t(e attle lo&t7

e!au&e t(e army wa& lo&t4 <(y wa& t(e army lo&t7

e!au&e t(e ri$er wa& lo&t5 <(y wa& t(e ri$er lo&t7

e!au&e t(e (or&e wa& lo&tD <(y wa& t(e (or&e lo&t7

e!au&e t(e &(oe wa& lo&t<(y wa& t(e &(oe lo&t7

e!au&e t(e nail wa& lo&tE <(y wa& t(e nail o+ t(e &(oe lo&t7

7

65



Notes on Root Ca"se Ana&(sis

i !ultie& in tra!king $own t(e root !au&e&<(ere $o you $raw t(e line7

At t(e Joint Genture7

At t(e Parent Com'any7

At t(e Client7

At t(e -egulator7At t(e ig ang H !reation o+ t(e univer&e7

<(at are t(e &to' rule&7

T(ere are no natural reak0'oint&* only arti.!ially im'o&e$ one&

T(e goal i& to e&ta li&( w(at (a''ene$ an$ (ow to &to' it (a''ening again

T(e logi!al &to' 'oint woul$ &eem to e w(ere manager& mig(t rea&ona ly ee/'e!te$ to e/er!i&e !ontrol

A &a$ &tory will (el' to illu&trate t(i& 'oint

6D



Cherno*(&

A!a$emi!ian Galeri ega&ov wa& t(e 'rin!i'le inve&tigator o+ t(e C(erno ylrea!tor $i&a&ter >e wa& al&o t(e #oviet nion%& !(ie+ &'oke&man at t(einternational !on+eren!e on t(i& a!!i$ent At t(i& meeting ega&ov 'ut t(e

lame +or t(e $i&a&ter &)uarely on t(e error& an$ violation& o+ t(eo'erator& ater (e !on.$e$ to +rien$&* I tol$ t(e trut( at t(e !on+eren!e*

ut not t(e w(ole trut(% Two year& later (e (ange$ (im&el+ a+ter re!or$ing(i& innermo&t +eeling& a out t(e a!!i$ent to a ta'e re!or$er 6

A+ter eing at C(erno yl* I $rew t(e une)uivo!al!on!lu&ion t(at t(e a!!i$ent wa& t(e &ummit o+ all t(ein!orre!t running o+ t(e e!onomy w(i!( (a$ een goingon in our !ountry +or many year& 2

6 Managing t(e -i&k& o+ 8rgani&ational A!!i$ent& H Jame& -ea&on* A&(gate Pu li&(ing I# , ; E060E4 6406 504

2 T(i& )uotation i& taken +rom t(e ega&ov Ta'e&* a tran&!ri't 're'are$ y t(e # e'artment o+ =nergy in 6;EE T(e original materiala''eare$ in Prav$a &(ortly a+ter ega&ov%& $eat(

6



An a&ternati)e metho! of root ca"seana&(sis

6E

What was s"ppose! tohappen?• ========================• ========================• ========================• ========================•

========================• ========================

Wh( was there a!i>erence?• ========================• ========================• ========================• ========================•

========================• ========================

What act"a&&( happene!?an! !i! we get h"rt?@

• LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL• LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL

What ha)e we &earnt?&"s actions

• LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL • LLLLLLLLLLLLLLLLLLLLLLLL



#ish-*one ana&(sis to n! root ca"se

6;

Pro lem

Main Fa!tor 6 Main Fa!tor 2 Main Fa!tor 3

Main Fa!tor 4 Main Fa!tor 5 Main Fa!tor D

Pro a le !au&e 6 2

Pro a le !au&e 6 3Pro a le !au&e 6 6

Pro a le !au&e 2 6

Pro a le !au&e 2 2

Pro a le !au&e 3 6

Pro a le !au&e 3 2

Pro a le !au&e 4 6 Pro a le !au&e 4 2

Pro a le !au&e 5 6Pro a le !au&e 5 2

Pro a le !au&e D 6

Pro a le !au&e D 2n$erlying !au&e 4 6 6 n$erlying !au&e 4 2 6

n$erlying !au&e D 2 6



Worke! examp&e of sh*one ana&(sis

2

=m'loyee& ru$e

to!u&tome

r

Pro!e$ure& Peo'le

=)ui'ment Poli!ie&

=m'loyee&e/'e!te$ to

'er+orm ta&k& t(atre$u!e time &'ent

on !u&tomer

&ervi!e

ow 'ay

=m'loyee& not motivate$

Provi$e )ui!k &ervi!e to !u&tomer&

Cu&tomer i& alway& rig(t

Ina$e)uate training

a!k o+ re!ognition

#u'ervi&ora&&ign&

unreali&ti!workloa$

Managementnot &en&itive to

em'loyee!on!ern&

en$ t(e rule& to &ati&+y !u&tomer

=t!

=t! =t!



Acceptance

26

I will not a!!e't

ina$e)uately!om'lete$ +orm&*mi&&ingin+ormation et!

I+ I t(ink 2 3 arerea&ona ly ok* Iwill 'ut +urt(ergui$eline& in t(e!omment& o/

-eNe!te$ +orm&will return toPart& 2 an$ 3At t(at 'ointt(e name& o+t(e a!tionee&!an e !(ange$i+ nee$e$



C&os"re

22

• T(e Clo&ure mu&t e !om'lete$in +ull• all t(e evi$en!e mu&t eu'loa$e$ to t(e t(ree &e!tion&• In!lu$e (y'erlink& a& a la&tre&ort ?t(ey may move or e$elete$@• >ig(lig(t t(e wor$ +or e/am'leCli!k >ere• Pre&& Ctrl K • Pa&te t(e we a$$re&& into t(e'o'0u' menu

http://var/www/apps/conversion/tmp/scratch_4/Root%20Cause%20Analysis.pptx

http://var/www/apps/conversion/tmp/scratch_4/Root%20Cause%20Analysis.pptx



C&os"reAppro)a&

23

• I will not !lo&e out

t(e ,C- i+ t(eevi$en!e i& not'rovi$e$ or t(e a!tionto 'revent re!urren!ei& not a$e)uate

• T(e o!al Pro!e&&8wner i& re)uire$ to&ign o1 t(e ,C- toin$i!ate t(at (e O &(ei& &ati&.e$ t(at t(ea!tion& are &uita le

an$ to un$er&tan$t(at t(e ,C- maynee$ to e in!lu$e$in t(e 'ro!e&& reviewin'ut



#"rther Training A)ai&a*&e - 7

24



#"rther Training A)ai&a*&e - 2

25



An(0"estions?

Comments? %ther

Concerns?

2D



27



2E



2;



3



36



32



33



34