Preparing for an internal/external audit & addressing internal/external non-conformances/proble - PowerPoint Presentation

1. Preparing for an internal/external audit & addressing internal/external non-conformances/problemsMarco Brunato, Intertek SAI Global & Anastasia Hryciw de Reijke, NSF

2. IntroductionsFacilitators: Marco Brunato, Intertek SAI Global;Anastasia Hryciw de Reijke, NSFParticipants:Name, OA/Municipality, Role regarding DWQMS

3. OverviewBack to Basics:for those new to DWQMS;as a review for those who may be returning to the workplace;expectations;requirements;internal & external audits;continually improving;using your municipality’s internal & external corrective actions process knowledge.

4. Learning ObjectivesParticipants will have the ability to:Know the expectations (based upon your DWQMS role and duties) to prepare for internal & external DWQMS audits.Plan & prepare effectively & efficiently for internal & external DWQMS auditsIdentify & provide the required information to respond to non-conformances with respect to the DWQMS: containment plan, root cause analysis, corrective action plan, preventative action plan.

5. Preparing for an Audithttps://www.ontario.ca/page/ontarios-drinking-water-quality-management-standard-pocket-guide#section-0

6. Preparing for an AuditSystemRe-certificationRemote (due to Covid-19 Pandemic)On-SiteSurveillanceoff-site desk audit; however, some municipalities have on-site annual surveillance auditsLimited Scope Transitionaloff-site desk audit prior to a Full Scope Accreditation

7. Audit CoverageSystem – all elementsRemote – all elementsOn-site – all elementsSurveillance: 3, 4, 7, 8,19, 20, 21 and other elements where changes have been made and where previous NCRs were raised, and corrective actions must be verified.Limited Scope Transitional: 3, 4, 6, 9, 11, 13, 16, 17, 18

8. Remote AuditsEnsure technology is availablewi-fi and cell serviceMust have the means to scan hardcopy recordsPhotos must display a dateInterviews must be initiated on camera to confirm identitiesEnsure management review and internal audits are completedEnsure any previously issued NCRs have been acted upon and evidence is availableEnsure documents (procedures and records) are available electronicallyMake arrangements with management team to hold an opening and closing meeting with the auditor

9. On-siteEnsure management review and internal audits are complete Ensure any previously issued NCRs have been acted upon and evidence is availableEnsure personnel are aware of responsibilities during the auditMake arrangements with management team to hold an opening and closing meeting with the auditor Have available all procedures and records on-siteEnsure a suitable workspace.

10. SurveillanceEnsure management review and internal audits are completeEnsure any previously issued NCRs have been acted upon and evidence is availableEnsure personnel are aware of responsibilities during the audit(for systems audits, identify a primary contact for your auditor who will be available to answer questions and/or provide any additional information, if requested) Have available all procedures and records

11. Limited Scope TransitionalHave available all procedures and recordsEnsure personnel are aware of responsibilities during the audit(for systems audits, identify a primary contact for your auditor who will be available to answer questions and/or provide any additional information, if requested)

12. Corrective & Preventive ActionDefinitions:Correction/Containment: Address the incident or symptom, steps taken to eliminate the identified symptoms along with others noted during the investigation. – From SAI/NSFCorrective Action: action to eliminate the cause of a detected nonconformity of the QMS with the requirements of the DWQMS or other undesirable situation – Pocket Guide V.2Preventive Action: action to prevent the occurrence of nonconformity of the QMS with the requirements of the DWQMS or other undesirable situation – Pocket Guide V.2

13. ContainmentDefinition: an immediate correction taken to contain the problem so it doesn’t spread:Describe steps taken to eliminate the identified symptoms along with others noted during the investigation;Provide evidence of completion. Equals correction – doesn’t need to be audit- related; can be simply problem-related as part of continuous improvement processExample i.e. AWQIFix it now.

14. Plan and Do Element ChangesElement 21 Continual Improvement PLAN – The Operating Authority shall develop a procedure for tracking and measuring continual improvement…reviewing and considering applicable best management practices, including any published by the MECP and available on www.ontario.ca/drinkingwater, at least once every thirty-six months;

15. Plan and Do Element ChangesElement 21 Continual Improvement PLAN b) documenting a process for identification and management of Quality Management System Corrective Actions that includes:i. investigating the cause(s) of an identified non-conformity,ii. documenting the action(s) that will be taken to correct the non-conformity and prevent the non-conformity from re-occurring, andiii. reviewing the action(s) taken to correct the non-conformity, verifying that they are implemented and are effective in correcting and preventing the re-occurrence of the non-conformity.

16. Plan and Do Element ChangesElement 21 Continual Improvement New addition PLAN c) documenting a process for identifying and implementing Preventive Actions to eliminate the occurrence of potential non-conformities in the Quality Management System that includes:i. reviewing potential non-conformities that are identified to determine if preventive actions may be necessary,ii. documenting the outcome of the review, including the action(s), if any, that will be taken to prevent a non-conformity from occurring, andiii. reviewing the action(s) taken to prevent a non-conformity, verifying that they are implemented and are effective in preventing the occurrence of the non-conformity.

17. Plan and Do Element ChangesElement 21 Continual Improvement DO requirement The Operating Authority shall strive to continually improve the effectiveness of its Quality Management System by implementing and conforming to the procedure.

18. Corrective ActionAddress root causeImplement action to address cause (not correction)Monitor to ensure no recurrence of the cause of the finding (EFFECTIVENESS) (not the same as preventive action)NCRs internal & external, inspection by MECP, DWS failures, repeat AWQIs customer complaints.

19.

20. SAI/Global-Intertek

21.

22. Preventive ActionRisk Identification & Mitigation planProcess Control data charts & trendsOpportunities For Improvements from all auditsBest Management Practices from various sources (i.e., licensing inspections, etc.)

23. ReviewReview of Containment Plans (correction) vs. Corrective Action Plans (prevention) and Root Cause Analysis (people, equipment, environment, process) including the 5 why’s fishbone diagram.

24. Group WorkEach group will receive a non-conformance that was prevalent across DWQMS in 2022Based on this breakout session, what measures will you take to “solve the problem”:Element 5 Document & Records ControlElement 12 CommunicationsElement 13 Essential Supplies & ServicesElement 17 Measurement & Recording Equipment, Calibration & MaintenanceElement 19 Internal AuditsElement 20 Management Review Element 21 Continual Improvement

25. Group WorkBest Practices for Problem Solving wrap-up

26. Questions???

27. WCWC is committed to supporting the owners, operators and operating authorities of Ontario’s drinking water systemsHands-on trainingPublic & on-site coursesHelplinePilot testingDrinking Water Resource LibraryVisit wcwc.ca for more information!