ACTION FOR IMPROVEMENT

Q97. What are corrective actions?

Preventive and corrective actions[1] are generated within an effective safety management system (SMS) as a significant part of the continual improvement process and can be defined as: "agreed actions taken to eliminate an occurrence (preventative) or recurrence (corrective) of an unsafe act, unsafe condition or other undesirable situation". These actions can be generated from safety management activities, such as:

• Internal audit reports (generated from audit activities from within the organisation, such as cross audits or department audits).

• External audit reports (generated from an external third party assessment of the organisation).

• Accident and incident investigations.

• Near-miss reports.

• Unsafe act and unsafe condition observation reports.

• Safety meetings.

• Management reviews.

Of course, the effectiveness of preventive and corrective actions in the continual improvement process depends on:

• The effectiveness of the systems in place to ensure that responsibilities and accountabilities are clearly defined to make sure that corrective actions are taken care of (do job descriptions within the organisation specifically state that incumbents are responsible for managing corrective actions assigned to them?).

• Adequate resources available to ensure that corrective actions are completed.

• A system is in place to monitor the effectiveness of managing corrective actions.

Corrective actions are a useful metric for organisations to measure corporate and individual performance. For example, in developing annual safety objectives (either for their organisation as a whole or for a specific project), you could develop a safety objective that: "75% of all corrective actions should be closed out by the original assigned close-out date". In the annual management review, this objective would be assessed and, if not met, recommendations made or, if met, safety incentives or rewards given to the responsible person(s). The success rate for the management of corrective actions could be used as part of a safety performance review for individual managers.

Q98. How do we manage corrective actions effectively?

Once preventive and corrective actions have been generated (from the many activities of the safety management system (SMS)), the next step is to ensure that these actions are dealt with in a timely and efficient manner. This is normally achieved by creating a central register for all actions generated, often called a 'Corrective Action Plan' (CAP).

Management of the CAP depends on how the SMS has been developed, whether it is part of a customised software application, a spreadsheet application or a paper system. Regardless of how the CAP has been implemented, there should be a management procedure to explain how it is organised and managed.

Corrective action plans often are customised to the specific requirements of the organisation, but the following elements should be considered as the minimum:

• Item number: All actions should be assigned a unique item or action number, even across large organisations and business units where a common register is used.

• Action date: The date that the action was generated. This date is easy to identify from near-miss reports, accident investigations and unsafe act / condition reports, but may be more problematic from audits that run over several days and where it may not be possible to identify a specific day for a specific action. In this case, use the date of the audit closing meeting.

• Observation: Comments on the original observation made on the report card or audit that requires corrective action.

• Action: The specific corrective action required to eliminate or manage the issue noted in the observation.

• Department: For organisations with several internal departments, or for CAP plans that are set up for projects and where a number of contractors may be involved, this section can be used to define which department / contractor is responsible for an action.

• Assignee or responsible person: The name of the person who has been assigned the responsibility to manage the corrective action. It is important to note that this person should have the authority and access to available resources to be able to deal with the corrective action effectively.

• Target date: Target date is the date when the action should be closed out. It can be difficult to assign specific dates for actions, especially where there could be an unknown lead time in ordering equipment or some research is needed to find the best solution to a problem. In such cases, a default time period can be assigned to actions initially - for example, four weeks from the action date - and adjust as necessary.

• Source (Forum): Since a comprehensive SMS generates actions from a wide range of sources, it is useful to track these. It is not always obvious from the observation text where the action came from (such as an unsafe condition report) so detailing the source is vital, especially from audits where it may be necessary to review the audit report itself to understand the detail or context of an action. Examples of sources relating to the forum include observation cards, safety meetings, audit and inspections, etc.

• Source (Location): For organisations with multiple work sites or locations, it is useful to identify which physical locations are generating input into your system. Examples of sources relating to location include factory, warehouse or office locations, business units, operational teams, etc.

• Priority: It is inevitable that corrective actions will need to be prioritised by assigning a priority tag such as 'Urgent, High, Medium or Low', or some other prioritising system. Whatever system is used, define what these terms mean - for example, 'High' may be defined as 'Must be closed out within 7 working days' and 'Medium' as 'Must be closed out within 1 month' or whatever is suitable and appropriate.

• Date closed: The date that the action has been dealt with and is no longer active.

• Status: The status of a corrective action can change over time, so an organisation should decide on what tags are to be used to identify the status of corrective actions. Examples include:

• Open / Work-in-Progress (WIP) / Active - a corrective action that is still being dealt with.

• Overdue - a corrective action that is still active or open beyond the stated target date. The assignee must not allow an action to become overdue, but should assign a new target date if there is a valid reason why the original target date is no longer achievable.

• Rejected - a corrective action that has been rejected. Actions can be rejected by the responsible person if there is a legitimate reason to do so.

• Closed - a corrective action that has been completed to the satisfaction of the responsible person and verified.

• Planned - a corrective action that is still active but cannot be completed until some other significant scheduled activity in the future (such as a maintenance shut-down or refit, etc.).

• Comments: Comments should be added by the responsible person on the progress of the corrective action. For example, if a spare part has been ordered to fix a corrective action, a comment outlining the order / requisition number or purchase order placed helps to keep everyone informed as to the ongoing status of the action.

Whatever corrective actions are decided on, ensure that they are SMART,: S - Specific; M - Measurable; A - Attainable; R - Realistic; and T - Time-bound.

Q99. What is continual improvement?

Continual improvement is the process of taking all the data generated from your operating safety management system (SMS), reviewing it against the internal and external standards that you use and then making changes to your system to improve it. Once your SMS has been defined and is fully operational for a period of time, you should be generating a wide variety of data in a number of ways, all of which can contribute to the improvement process.

The continual improvement process should be defined within your own organisation and should outline which elements of your safety management system are included. You may expect to see some or all of the following (or generate your own additional items) as possible components of this process:

• Review of policy statement objectives and aims.

• Review of occupational safety and health objectives.

• Analysis of leading and lagging performance indicators.

• Analysis and review of risk assessments.

• Review of remedial actions from all audits, inspections and checks.

• Conclusions and findings from accident and incident investigations.

• Feedback from employees (from forums such as safety meetings, safety committees, suggestions for improvement and safety representatives, etc).

• Conclusions from management reviews.

• Reviews of procedures and documentation for compliance with new and evolving Acts, regulations, industry Codes of Practice and industry standards.

• Reviews of procedures and documentation to ensure continuing compliance with, and relevance to, your operations.

• Conclusions and findings on the effectiveness of occupational health promotion schemes.

• Review of training standards (or delivery methods) applicable to your industry sector.

• Periodic performance reviews of employees where health and safety compliance is included.

Q100. Why is continual improvement important?

From the first Model T to new electric or hydrogen-powered cars, from the Wright Brothers' first flight to Concorde and from the first Sputnik satellite to the International Space Station, striving for continual improvement is a major component of the human condition. In the 21st century, we do not have to look too far to see the continual improvement process in action. We change our consumer goods on a regular basis as the relevant technologies continually improve, and we have an assumption that the services that are provided to us (such as hospitals, public transport, the road network, schools, etc.) also will evolve, delivering improved performance and higher standards year on year. Indeed, we are so used to it being a part of our everyday lives, we may not even realise how embedded the improvement process is into all aspects of our society.

Your organisation's safety management system (SMS) is the same - without an ongoing continual improvement process, your system will stagnate, become outdated and, in all likelihood, will start to deviate from legal compliance requirements, which negates the whole purpose of having a SMS in the first place.

So, as the world continues to change around us all, your SMS also must continually improve to keep up with those changes. For each and every SMS, there is a need to identify and document which internal and external elements are critical in the improvement cycle, to learn from them and then to implement change.

ABOUT THE AUTHOR

ANDY TILLEARD is a Chartered Member of the UK Institution of Occupational Safety and Health (IOSH), a Full Member of the International Institute of Risk and Safety Management (IIRSM) and is registered as a European Safety and Health Manager as outlined by the European Network of Safety and Health Professional Organisations (ENSHPO).

  • [1] Corrective actions also are known as remedial actions, action items and non-conformity reports although the term 'non-conformity' can have specific legal definitions in some regulations.
 
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