RWANDA STANDARDS

BOARD

NATIONAL CERTIFICATION DIVISION

TITLE: IDENTIFICATION No. AUTHOR:

PROCEDURE NCD/PRO/05 QUALITY MANAGEMENT

ON CORRECTIVE ACTION SYSTEM OFFICER

AUTHORIZATION

THIS PROCEDURE IS ISSUED UNDER THE AUTHORITY OF:

Antoinette Mbabazi, MSc. BAJENEZA Jean Pierre
NAME:

TITLE/POSITION: Ag.NATIONAL CERTIFICATION DIVISION MANAGER

SIGNATURE:

ISSUE DATE:

DOCUMENT CONTROL:

CONTROLLED WATER MARKED/STAMPED

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Title: Procedure on Corrective Action Page 2 of 5

TABBLE OF CONTENTS

1. PURPOSE........................................................................................................................................... 2

2. SCOPE................................................................................................................................................. 3

3. PRINCIPAL RESPONSIBILITIES................................................................................................ 3

3.1 All staff..................................................................................................................................................... 3

3.2 The QMSO................................................................................................................................................ 3

3.3 Top Management.................................................................................................................................... 3

4 PROCEDURE DETAILS................................................................................................................. 3

4.1 Identifying non conformities................................................................................................................. 3

4.2 Determining Causes............................................................................................................................... 4

4.3 Evaluate Need for Action....................................................................................................................... 4

4.4 Development of the corrective action plan......................................................................................... 4

4.5 Implementation of Corrective Action................................................................................................... 5

4.6 Monitoring and Verification................................................................................................................... 5

4.7 Records.................................................................................................................................................................5

Revision: 06532 Date of Approval: 0652908/05321104/20210196

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Title: Procedure on Corrective Action Page 3 of 5

1. PURPOSE

To ensure that any corrective action taken to eliminate the causes of actual non-conformances is
appropriate to the magnitude of the problem whilst also being in proportion to the risks presented
by the non-conformance. Root causes of non-conforming services, as well as, management
system defects are investigated and actions implemented to prevent their recurrence

2. SCOPE

This procedure defines the process for identifying, documenting, analysing and implementing
corrective actions to the detected non conformity in order to eliminate the actual causes of non
conformity in RSB certification service delivery.
This procedure is applicable to all corrective actions related to non-conforming NCD services,
client complaint, management review, customer feedback, monitoring and evaluation activities and
audit results.

3. PRINCIPAL RESPONSIBILITIES

3.1 All staff

a) Report any failure in the service delivery

b) Follow this procedure upon detection of a potential non-conformance

c) Determine the causes and implement the corrective action.

3.2 The QMSO

a) Follows up and evaluates the effectiveness of Corrective Actions taken

b) Maintains a System for reporting and record keeping

3.3 Top Management

a) Avail resources for the implementation of corrective action

b) Review the effectiveness of Corrective Actions taken

4 PROCEDURE DETAILS

4.1 Identifying non conformities

4.1.1 Non conformities can be identified through external assessment activities or internal audits.
Non conformities from internal audits are recorded on the Corrective Action Request (CAR) Form
NCD/FOM/2104. upload the right form

Revision: 06532 Date of Approval: 0652908/05321104/20210196

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4.1.2 Non conformities can also be identified through the complaint handling process as recorded
on the complaints and appeals form NCD/FOM/101 and management system complaints register
SCU/REG/02.

4.1.3 Non conformities can be raised by staff during their operations.

4.1.4 Data from surveys conducted on clients and interested parties for feedback regarding NCD
services using the Client Feedback Form NCD/FOM/06 can help to identify non conformities.

4.1.5 Monitoring and evaluation of the management system processes can highlight non
conformities.

4.1.6 Management review meetings can identify non conformities or weaknesses in the quality
management system.

4.1.7 By whichever means a non-conformance is identified, it is reported to the relevant Director

for consideration. On ascertaining that the raised issue is a non conformity, then ensures that a
Corrective Action request (CAR) form NCD/FOM/2104 (upload as corrected) is filled and
forwarded to the QMSO. The QMSO reviews the issue in consultation with the NCD Manager for
handling.

4.2 Determining Causes

4.2.1 The NCD Manager constitutes a team to investigate the root cause of the non conformity
they may do a brain storming session using effective tools such as the 5 Whys or the PARETO
analysis or fishbone diagram also known as Ishikawa diagram.

4.2.2 The team considers all circumstances related to the problem such as personnel, training
with the aim of finding the root cause.

4.3 Evaluate Need for Action

The team evaluates the need for action to ensure that the non-conformance does not recur. If
Corrective Action is necessary then the team decides what action to be taken.

4.4 Development of the corrective action plan

4.4.1 The appointed team enters raised non conformities into Corrective Action log NCD/FOM/05
which indicates the following: CAR no., issue date, non conformity, action to be taken, the person
responsible, extent analysis, area/unit, and completion date and verification for effectiveness.

4.4.2 The team leader verifies the effectiveness of the proposed corrective action if they were
raised as a result of an internal audit.

4.4.3 In the event where the raised non conformity originated from any other source a team
comprising the QMSO verifies the effectiveness of the proposed corrective action.

Revision: 06532 Date of Approval: 0652908/05321104/20210196

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4.4.4 The NCD Manager approves the log for implementation and communicates to relevant
person(s) as appropriate to ensure implementation.

4.5 Implementation of Corrective Action

4.5.1 The plan is communicated to the concerned staff for implementation. Actions may include
the following:

a. Staff training, refresher sessions, brain storming session

b. Creation or modification of the documents

c. Following the procedure strictly

d. Recruitment of staff

e. Process change or a combination of them.

4.5.2 Designated personnel must implement the agreed level of action within an agreed
timeframe.

4.6 Monitoring and Verification

4.6.1 The Quality Management System Officer monitors the implementation of the corrective
action to ensure timely completion of any open Corrective Action or for providing evidence to justify
its continued open status.

4.6.2 If a non conformity has reoccurred, then this indicates that the analysis of root cause may
have been incorrect or incomplete or the level of action was not complete. In such circumstance
the evaluation process may be reviewed as decided by the Manager.

4.6.3 The Quality Management System Officer verifies the effectiveness of the Corrective Action
and closes out the Corrective Action.

4.6.4 Repeated non-conformances of the same nature or significant deviations from procedures
or policies are reported to Top Management for action and resolution. The underlying cause of the
non-conformance is investigated.

4.7 Records

All aspects of the non conformity, Corrective Action Request (CAR) form, investigations, the root
causes, Corrective Action proposed, and completion date are recorded and maintained in
electronic form on the corrective action log NCD/FOM/05..

Revision: 06532 Date of Approval: 0652908/05321104/20210196