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7 Steps to Writing a CAPA Procedure Compliant with ISO 13485:2016

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This article lists 7 steps to writing a more effective CAPA procedure, ensuring that your procedure is risk-based and training people effectively.CAPA SOP 1024x288 7 Steps to Writing a CAPA Procedure Compliant with ISO 13485:2016

During a recent internal audit I was performing for a new client, I noticed that they were not meeting one of the requirements of their CAPA procedure. Specifically, the procedure indicated that all CAPA plans must be written within seven calendar days of initiating the CAPA. Despite this requirement in their procedure, the client was indicating that CAPA plans were due within 30 calendar days on their CAPA form.

This example is a minor nonconformity, but the reason why this client was not following their procedure is more interesting. The procedure was 100% compliant with FDA regulations, but the procedure did not match how the company performed the process. The procedure and the process MUST match.

This client purchased their CAPA procedure from a consultant, changed the title, and had everyone in the company “read and understand” the procedure for training. If this sounds like your company, I’m not surprised, because this is not uncommon. To avoid the mistakes this client made, follow the following steps for writing your own CAPA procedure.

7 Steps for Writing an Effective CAPA Procedure

  1. Design your CAPA form first
  2. Identify which steps in your process are most important and specify how these steps will be monitored (i.e., risk-based approach)
  3. Write a procedure that follows your CAPA form and includes instructions for monitoring and measuring your CAPA process
  4. Conduct group CAPA training using the draft version of your form and procedure
  5. Make revisions to the form and procedure to clarify steps the trainees had difficulty with
  6. Ask the trainees to review the revised form and procedure
  7. Make final revisions and route the procedure for approval

The specific order of steps is important to creating a CAPA procedure—or any procedure. Writing a procedure that matches the form used with that procedure helps people understand the tasks within a process.

Make sure your CAPA procedure is clear and concise

Procedures are often unclear, because the author is more familiar with the process than the intended audience for the procedure. An author may abbreviate a step, or skip it altogether. As an author, you should use an outline format and match your CAPA form exactly. There should be nothing extra in the procedure and nothing left out. In fact, my CAPA procedure is only 4 pages.

Corrective and Preventive Action CAPA Procedure 7 Steps to Writing a CAPA Procedure Compliant with ISO 13485:2016
Corrective and Preventive Action (CAPA) Procedure/Form

The CAPA procedure is a 4-page procedure which includes a CAPA form, and CAPA log. The procedure is compliant with ISO 13485:2016 and 21 CFR 820.100.

Price: $299.00

Ensuring your CAPA procedure is risk-based

The biggest problems most companies have is that quality personnel has primary responsibility for the CAPA process. Quality personnel should be monitoring and measuring the CAPA process and reporting on process effectiveness to top management–not doing all the work associated with every CAPA. When you first initiate a CAPA, someone needs to perform an investigation to determine the root cause. This person will need to review records and analyze data. Based upon the data analysis, you may determine that a CAPA is not needed, but you will continue to monitor the process. Other times, the data analysis will verify that you have a systemic problem and a formal CAPA is needed. Based upon the severity of a quality problem, and the frequency of that problem, you should prioritize the CAPA as low, medium or high risk. Top management should prioritize resources for completing the CAPA based upon the risk. Quality should monitor implementation and closure of CAPAs and report to top management. Finally, sometimes you have a larger problem that requires a quality plan to make changes throughout your quality system. Implementing this risk-based approach will also meet the requirement in ISO 13485:2016 for implementing a risk-based process.

Verifying effectiveness of a CAPA is the most important step in the process

Most people verify CAPA effectiveness by verifying that all the actions planned were completed, but this is not a CAPA effectiveness check. An effectiveness check should use quantitative data from your investigation of root cause as a benchmark. Then you should verify that the performance after corrective actions are implemented resulted in a decrease in the frequency of the quality problem, a decrease in the severity of the quality problem, or both. Ideally, a process re-validation was performed, because validation protocols are required to include quantitative acceptance criteria for success.

Training on your new CAPA procedure

If you are interested in more training on CAPA, you might be interested in purchasing Medical Device Academy’s Risk-Based CAPA webinar. 99% of companies hold off on their training until a procedure is officially released as a controlled document. In my experience, however, these procedures seem to have a lot of revisions made immediately after the initial release. New users ask simple questions that identify sections of procedures that are unclear, or were written out of sequence. Therefore, you should always conduct at least one training session with users prior to final review and approval of a procedure. This will ensure that the final procedure is right the first time, and it will give those users some ownership in the new procedure.

After you train your initial group, and after you make the edits they recommended, ask those trainees to review and edit your changes to the procedure. Sometimes we don’t completely understand what someone is describing, and sometimes may be only half listening. Going back to those people to verify that you accurately interpreted their feedback is the most important step for ensuring that users accept your new procedure.

After you approve your new CAPA procedure, make sure everyone in your company is trained on the final version of the procedure. CAPA is a critical process (i.e., “the heart”) in your quality system. Everyone should understand it. You should also provide extra CAPA training for department managers, such as root cause analysis training, because they will be responsible for implementing CAPAs assigned to their department. You can use this 7-step process for any procedure, but ensure you use it for the most important process of all—your corrective and preventive action process.

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Effective Management Solutions for 10 CAPA Program Blunders

The author provides effective management solutions for 10 real-life CAPA program blunders., (i.e., procedures, root cause analysis, closing CAPAs, etc.)

%name Effective Management Solutions for 10 CAPA Program Blunders

Effective Management Solutions for 10 CAPA Program Blunders

I am always looking for new and creative ways to help people understand the importance of maintaining an effective Corrective and Preventive Action (CAPA) program. If my last dozen CAPA blogs were not convincing enough, maybe this list of suggestions will help.

  • 1. If someone doesn’t follow procedures, just fire them. The employee in question is obviously the root cause. Management cannot be held responsible for the actions of employees. Once, I read a corrective action plan that indicated termination was the correction for a missing training record. The QA Manager clarified this statement by saying that the employee resigned for personal reasons, and there was no opportunity to train the employee. The CAPA record also indicated that 100% of the training records for manufacturing employees were reviewed for completion. There were a few records identified as incomplete, and those employees were trained—not terminated. The company also implemented a tracking tool to monitor training records. As a general rule, termination is not an acceptable corrective action or correction.
  • 2. If CAPAs are open longer than your procedure allows, close the existing CAPAs the day before the CAPAs become overdue, and open new CAPAs. CAPAs are not “closed” until all nonconformities have been corrected, corrective and preventive actions are implemented, and effectiveness checks are done. If the corrective and preventive actions were not completely effective, some companies chose to reopen the record and expand the plan of corrective and/or preventive actions. Other companies chose to open a new CAPA record, and reference the new record in the effectiveness check section of the previous CAPA record. Either approach works, but you cannot close an incomplete record and remain compliant.
  • 3. To verify effectiveness of corrective actions, just include a copy of your document change order. Documenting changes to procedures meets part of the CAPA requirements, but this verifies implementation—not effectiveness. In order to verify effectiveness, you need to verify that a nonconformity, or a potential nonconformity, will not recur. Low frequency defects are often hard to directly demonstrate. The best approach is to validate the process parameters to demonstrate quantitatively that the process capability has improved. For manual processes, you may need to test the new process to verify that the error will not occur, or will be detected.
  • 4. If you can’t finish tasks on schedule, revise your plan. If you still can’t finish tasks on schedule, revise your plan again—and again. It’s appropriate to revise your plan if you discover additional causes that your initial investigation missed. You should not, however, be revising target completion dates—except in rare cases. You also should not need to revise your plan multiple times.
  • 5. When you’re unsure why a problem occurred, identify the root cause as an unclear procedure and make a minor change to the appropriate SOP. Making changes to procedures is quick and easy to verify. Unfortunately, this approach is seldom effective at preventing recurrence. You need to develop new process controls to make errors impossible. Eliminate variation in raw materials, eliminate subjectivity in inspections and provide tools and fixtures to make manual processes capable of more consistent results. After you have reduced all three of these sources for process defects, then you are ready to revise your procedures and retrain employees.
  • 6. Whenever an employee fails to follow a procedure, just change the procedure to require another person to verify that they did it right. If one employee fails to follow procedures 100% of the time, a second person manually inspecting will also not be 100% effective. Another method of process control should be used to ensure that your process results in conforming product. Adding more people provides a false sense of confidence. The use of objective measurement and go/no go fixtures provides a higher degree of certainty.
  • 7. Write a justification for extension of the implementation timeline if a CAPA is about to become overdue. Justifications for extension provide objective evidence that management is aware that a CAPA plan is not meeting the target completion times. This is necessary on rare occasions, but extensions should never become routine. Also, if the progress of a CAPA is slow, monitoring should be frequent enough that management can release additional resources, or re-prioritize assignments in order to catch-up with the target completion date.
  • 8. Use the “5 Why” technique for root cause analysis to identify a user error to blame for complaints. The “5 Why” technique is effective at investigating the depth of a problem to ensure that the root cause is identified—instead of a symptom. If the reason for a problem is identified as a supplier, then it is necessary to ask why the supplier’s error was not prevented or detected. Sometimes this requires asking “Why” more than five times, but identifying a cause you have no control over will fix nothing
  • 9. To monitor your CAPA program, conduct weekly CAPA board meetings where a person is asked to explain why the CAPA they were assigned is overdue. Anyone can make an excuse, but excuses will not complete CAPAs. CAPA boards and weekly meetings can be extremely valuable, but your CAPA board should rely on three rules: 1. Managers need to be present in order to re-allocate resources and re-prioritize tasks. 2. CAPAs that are on schedule or ahead of schedule require no further discussion. 3. Anyone assigned to a CAPA that is behind schedule should request help and suggest solutions prior to the CAPA becoming overdue.
  • 10. Do not assign other departments the responsibility for CAPAs, because only QA has the training and competency to conduct an investigation of root cause, and write a CAPA plan.  One of the most effective CAPA management tools I observed was a visual communication board that used color coded paperclips which identified resources assigned to CAPAs. By limiting the number of paperclips to equal the number of resources allocated to CAPAs, that company was able to level the workload of CAPA assignments to match the available resources in each department. You can only achieve this level of efficiency and effectiveness if multiple people in multiple departments are trained and competent to investigate root cause and write CAPA plans. CAPA should be a core competency for every department, because it’s the best process for fixing and preventing problems.

Disclaimer: If you missed my sarcasm, these are ten ways to mis-manage a CAPA program. The brief paragraph after each numbered example is intended to provide the actual recommendation for effective management of your CAPA program.

%name Effective Management Solutions for 10 CAPA Program BlundersIf you are interested in learning more about CAPA, please register for the Medical Device Academy’s CAPA Workshop on October 3 in San Diego. Click here to register for the event: http://bit.ly/MDAWorkshops.

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How to Utilize CAPA Training To Avoid FDA 483 Citations

By Guest Blogger – Susan Christie

%name How to Utilize CAPA Training To Avoid FDA 483 Citations

The author discusses how formal CAPA training can help solve the four most common CAPA deficiencies, and help avoid FDA 483 citations.

Corrective And Preventive Action (CAPA) is considered to be one of the most critical processes in a Quality Management System (QMS). CAPAs prevent nonconformities from recurring, as well as identify potential problems that have may occur within the QMS.

Both the CFR (820.100) and the ISO 13485 Standard (8.5.2 and 8.5.3, respectively) include similar requirements for establishing and maintaining a compliant CAPA process. The concept seems pretty straightforward, right?

Then why do so many companies struggle with this process, and go into panic mode during FDA inspections and Notified Body audits?

CAPA process deficiencies have long been the number one Good Manufacturing Practice (GMP) violation cited in FDA Warning Letters. Therefore, providing trained experts to teach the CAPA process is well worth the investment to provide your employees with the expertise needed to implement a sustainable, effective and compliant process. Support from top management is a must for success.

7 Reasons Why There is LIttle Support for the CAPA Process
  1. Managers view CAPA as a necessary evil and apply minimum effort and resources to complete the required paperwork.
  2. All complaints, audit findings, shop floor nonconformities, etc., go straight into the CAPA system, resulting in what is known as “Death by CAPA.” There are hundreds of CAPAs to be dealt with, but the CAPAs languish and quickly become a mountain of overdue records.
  3. The lack of ability to conduct effective root cause analysis results in, at best, a band-aid solution, and recurrence of the same issues time and again.
  4. There is no risk-based or prioritization process that provides a triage for determining when a CAPA is appropriate, and how to classify its criticality.
  5. CAPA forms are either too restrictive, such as using “yes/no” questions, thereby stemming the creative flow of process thinking or, too open-ended, leaving the CAPA owner with little guidance for getting to the true root cause.
  6. Trending and metrics that would highlight quality issues before they become complaints are lacking, so most CAPAs are last-minute reactions to a crisis, instead of proactive improvement projects.
  7. Senior management has not allocated sufficient time and resources to CAPA owners in order to develop expertise, and clearly do not understand the nuances of FDA compliance, the ISO Standard, and responsibilities of CAPA ownership.
Consequences of an Ineffective CAPA System: FDA 483 Citations Are Possible

FDA 483 observations, Warning Letters and loss of your ISO 13485 certification are possible consequences of failing to manage your CAPA process. Imagine explaining to your customers why you lost your certification, and why they should keep you as a trusted supplier. That is not a conversation you want to have.

A weak CAPA process allows nonconformities to recur, results in manufacturing downtime, requires rework, and ends with scrapping product or lost customers. The consequences of a weak CAPA process negatively impact your company’s financial strategy and goals.

In order to prevent an increase in the cost of poor quality, your business cannot remain static. You need to improve and adopt best practices. Your CAPA process is a systematic way to make those improvements happen.

Characteristics of an Effective CAPA system?
  • Easy to follow procedure
  • Defined CAPA inputs
  • Risk assessment and prioritization
  • Root-cause investigation tools
  • A well-defined action plan
  • Metrics to track progress
  • Communication of information and status
  • Effectiveness checks
  • Management support and escalation
What to Expect from Formal CAPA Training

Death by Powerpoint is not training (http://bit.ly/DeathbyPPT). Effective CAPA training requires hands-on participation in working through root-cause analysis with an expert. One of the best training tools are case studies based upon recent 483 observations. A CAPA training course should teach you how to:

  1. Accurately identify the cause of problems
  2. Prioritize your corrective and preventive actions using a risk-based approach
  3. Implement an appropriate corrective and/or preventive action, and
  4.  Verify effectiveness of your actions

CAPA training should teach you how to reduce the length and number of investigations. Training will also help you master current problem-solving methodologies to identify true root causes, utilizing facts, instead of guesswork or opinion. The proper identification of the true root cause of a problem is critical, because otherwise your CAPA plan will fail to fix real problems.

Not all formal training needs to be in-person. Face-to-face training can be supplemented with more cost-effective training of concepts using webinars and recorded presentations. Interactive training is needed to supplement this training, so that students can practice what they learn.

How Training Solves Common CAPA Deficiencies

The four most common CAPA deficiencies are:

  1. Inadequate procedures
  2. Incomplete investigations
  3. Overdue actions, and
  4. Failure to perform an effectiveness check

Each of these deficiencies are addressed directly by CAPA training. Formal CAPA training reviews each of the requirements for your CAPA process, and trainers will often share samples of CAPA procedures and CAPA forms that they wrote and found to be effective. Learning multiple root cause investigation techniques, and practicing them using the case study technique, ensure that CAPAs are thoroughly investigated, rather than identifying superficial symptoms.

CAPA metrics are introduced during training to ensure that the CAPA process owner knows best practices for monitoring and analyzing the process. Finally, CAPA training includes specific examples of what is, and what is not, a proper technique for performing an effectiveness check.

Results After Formal CAPA Training

The best reason for making formal CAPA training available to the people responsible for CAPAs are the results you will experience after the training. For example:

  1. Elimination of hundreds of overdue CAPAs
  2. Reduction in nonconformities, scrap, rework and customer complaints
  3. Lower overall costs associated with quality problems
  4. Better FDA inspection and Notified Body outcomes, and
  5. Safer products for your customer

%name How to Utilize CAPA Training To Avoid FDA 483 CitationsIf you are interested in learning more about CAPA, please register for the Medical Device Academy’s CAPA Workshop on October 3 in San Diego. Click here to register for the event: http://bit.ly/MDAWorkshops.

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Keeping Design Projects on Schedule: Using the CAPA Process

%name Keeping Design Projects on Schedule: Using the CAPA Process The author provides two steps to consider taking now and steps to take in the future that will help keep design projects on schedule using the CAPA process.

The ability to get new, high-quality products to market quickly is the most important core competency for a company to develop. What is your company doing to improve the performance of your design teams? If you have trouble answering the above question, you should consider performing a detailed internal audit of your design control process: http://bit.ly/AuditDesign.

The only significant change I would make to my recommendations from 2012 is to follow the GHTF guidance document for creating technical files using the STED format, instead of using NB-MED 2.5.1/Rec 5: http://bit.ly/GHTFSTEDGuidance. This approach to creating a technical file lends itself to meeting the Canadian Requirements for Medical Device Licensing, and this is the preferred format of Technical Files in Annex II of the proposed EU regulations.

At the end of the blog on how to audit design controls, Step 7 states that you should, “Ask the process owner to identify some metrics or quality objectives they are using to monitor and improve the design and development process…If there are no metrics being tracked by the process owner, you might review schedule compliance.” The two most common reasons why design projects are not able to keep pace with the design plan schedule are: 1) there are insufficient resources allocated for the project, and 2) the estimates of the duration for tasks in the schedule are too aggressive.

Step 1: Estimating Duration of Tasks

Task duration is the easiest quality objective to track performance against. Whether you track design projects with an Excel spreadsheet or Microsoft Project, you can easily compare the actual duration of any project task with the estimated duration that was planned at the beginning of the project. It is important to measure the duration in labor hours, rather than using the number of people, because most design team members are multi-tasking. You can and should mine the data from previous design projects, because this information is available now. As you go through historical data, you will also realize where there are weaknesses in how you capture data regarding labor hours.

Once you have the raw data, I recommend analyzing the data using % deviation and total hours. The % deviation will tell you which estimates were the least accurate, and the total hours will tell you which estimates have the most significant impact on the total project. Ideally, you will collect data from multiple projects, so that you can determine if the deviations are consistent from project-to-project.

This data analysis is important, because the data analysis will help identify the root cause for inaccurate task duration estimates. You may also want to perform a Pareto Analysis of the data to prioritize which project tasks would benefit most from more accurate estimates. Once you have identified the root cause for inaccurate estimates, you can initiate Corrective And Preventive Actions (CAPA), where appropriate.

Step 2: Allocation of Resources

You may heard the phrase “Do more with less” but I like to joke that design teams are expected to “Do everything with nothing.” If you design team is monitoring the accuracy of take duration estimates for design projects, the accuracy of your project plans should improve. Your management team should also develop a greater confidence in your teams’ ability to forecast product launch dates thereby the estimates for resource needs. Managers frequently challenge you to achieve the impossible.

The most famous example of this is when Steve Jobs challenged Steve Wozniak to design the video game Breakout in just a few days. If you are the next Steve Jobs, and you have Woz on your team, keep aiming for the moon. If your team consists of mere mortals, you might need more resources. Your senior management may not have additional resources to provide, but it is critical to accurately estimate the resources needed for projects. If you can estimate accurately, you will have the following impact on your company:

  1. You will be able to estimate the amount of time to market that can be reduced by adding resources.
  2. You will be able to estimate the cost impact of unrealistic management timelines—instead of saying “I can’t push it any faster Captain.” (my favorite Star Trek quote).
Future Steps: Preventive Actions

In one of my previous postings (http://bit.ly/PASources) I stated, “The most fruitful source of preventive actions, however, is data analysis of process control monitoring.” If you are monitoring and measuring your design control process, you can use this approach to:

  • Identify preventive actions for your design process
  • Establish specifications for critical path tasks in each project
  • Calculate your design process capability for successful completion based upon historical data

The answer to the following question may help you identify your next design process improvement. How close are your estimates to achieving a Cpk > 1.33 for completing design verification protocols on-time? %name Keeping Design Projects on Schedule: Using the CAPA Process If you are interested in learning more about CAPA, please register for the Medical Device Academy’s CAPA Workshop on September 9 in Orlando, or on October 3 in San Diego. Click here to register for the event: http://bit.ly/MDAWorkshops.

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How to perform a quantitative CAPA effectiveness check

This article reviews explains how to conduct a quantitative CAPA effectiveness check, and you will also learn three methods NOT recommended.

quantitative effectiveness check 1024x713 How to perform a quantitative CAPA effectiveness check

There are three methods NOT recommended for a CAPA effectiveness check:

  1. verifying the procedure was revised,
  2. verifying employees were retrained, and
  3. making sure mistakes don’t occur 3x in a row.

The best method is to establish quantitative criteria for effectiveness based upon data collected during the investigation of root cause. The graph above is an example of objective evidence that a preventive action was effective. The graph shows that the process capability (Cpk) was improved from 0.837 to 2.50 by changing a process set-point to adjust the mean of the dimension closer to the center of the specification range. This is typical of adjustments made during process validation and re-validation activities.

Incorrect Method 1: Verify the Procedure was Revised

When a nonconformity is identified during an audit, the laziest way to “fix” the problem is to revise your procedure. Despite the fact that most FDA 483s identify inadequate procedures as the reason for an observation, your procedures are seldom the problem. Your employees may not even be following the procedures. In fact, repeatedly revising procedures may actually be part of the problem. If you must revise your procedures, please involve the people that actually use the procedures.

Incorrect Method 2: Verify Employees were Retrained

During your last surveillance audit you may have revised the procedure, but your auditor noticed that there were no retraining records for employees that were performing the revised procedure. In fact, one interviewee was unable to identify where the new inspection step could be found in the revised procedure. It’s too bad the interviewee didn’t notice the bold and underlined text indicating recent revisions. Your auditor wonders how effective your retraining process is.

Incorrect Method 3: No Mistakes 3x in a Row

Last month a manufacturing engineer was assigned to perform an effectiveness check related to corrective actions implemented in the incoming inspection process. The procedure was revised to clarify the proper procedure for statistical sampling of rolls of plastic film as a corrective action. The engineer sampled the three most recent lots of the same plastic film that was incorrectly sampled in the past. All three lots were correctly sampled in accordance with the revised procedure. The engineer reported that the corrective actions implemented were effective. However, you have two new nonconformities on your desk from manufacturing related to incorrect sampling procedures during incoming inspection of other raw materials. Now you wonder if the incoming inspection procedure was the real root cause.

Corrective actions that are actually effective

Instead of adding something to your procedures each time someone makes a mistake, you might want to think about how you can simplify and streamline your procedures with fewer words. You can say things more clearly with pictures and flow charts instead of hundreds of words. Training effectiveness can be verified with exams that ensure employees “read and understand” your revised procedures. Finally, when you identify a nonconformity with one product, you need to ensure that you consider how similar mistakes might occur with similar products. Maybe you need a process for incoming inspection that doesn’t rely upon someone reading procedures.

You need to be objective to perform an effectiveness check

The biggest weakness of the auditing process is that it relies heavily upon the subjective opinion of an auditor. This is why auditors are supposed to audit against objective audit criteria in an international standard. The need for objectivity is also why there are guidance documents to clarify a consistent interpretation of those standards. Therefore, when you perform an effectiveness check, you also need objectivity. The best way to ensure objectivity is to establish documented criteria for effectiveness prior to finalizing your corrective action plan. Ideally, that will be in the form of a prospective process validation protocol with quantitative acceptance criteria.

How to ensure objectivity

The single best way to ensure objectivity when you are performing a CAPA effectiveness check is to define the post-implementation goal in terms of a quantitative quality objective. Ideally, you can graph the quality metric using historical data and current data. If you need statistical analysis to see a difference between pre- and post-implementation of the CAPA, then your CAPA was not effective. If your graph looks like a miracle happened and the metric changed almost overnight, and timing corresponds to the date your corrective action(s) was implemented, then your CAPA was effective.

How to set a quality objective for you CAPA effectiveness check

Some people have trouble with using a quantitative approach in performing effectiveness checks, because some things are harder to measure than others. However, you can measure anything. For example, you can even measure employees forgetting to initial and date changes to quality records. This can be done by identifying critical control points where quality records are reviewed and documentation errors are measured. You can measure by employee, by form, by month, etc. The key to monitoring and measuring a process is to answer the following questions:

  1. Who will measure it?
  2. What will be measured?
  3. Where will it be measured?
  4. When will it be measured?
  5. How will it be measured?
  6. How will measurements be analyzed?
  7. Who will data analysis be communicated to?

When to Perform a CAPA Effectiveness Check

Many companies set arbitrary deadlines for performing an effectiveness check (e.g., – between 30 and 60 days of implementation of corrective actions). Some companies use a risk-based approach to their CAPA process, and the urgency of effectiveness checks may be a function of risk. I recommend a completely different approach. Instead of using an arbitrary or risk-based approach, I recommend monitoring your new quality metric to estimate how long it will take to reach your new quality objective.
%name How to perform a quantitative CAPA effectiveness check

If you are interested in learning more about CAPA, click here to register for Medical Device Academy’s Risk-Based CAPA webinar.

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Where to Locate Preventive Action Sources

%name Where to Locate Preventive Action Sources

The author discusses why preventive action is important in developing a sustainable and robust quality system and where to locate preventive action sources.

Most ISO auditors and FDA inspectors view CAPA as one of the most important processes in your quality system, but the approach to preventive actions is distinctly different between the ISO Quality System Standards (i.e., – ISO 9001 and ISO 13485) and FDA regulations (i.e., – 21 CFR 820.100). Throughout the FDA QSR, corrective action and preventive action are always found together, while in the ISO Standards, preventive action is a separate clause (i.e., – Clause 8.5.3). The wording of the two clauses is nearly identical, but ISO certification auditors tend to be purists. Therefore, your ISO certification auditor will expect you to have at least some examples of CAPAs that are 100% preventive. In fact, many auditors will issue a nonconformity if you have no examples that are 100% preventive.

Why is Preventive Action Important?

While I was conducting certification audits, I noticed that the better quality systems tended to have several examples of preventive actions. There were a few companies that actually had more preventive actions than corrective actions, and the quality systems at those companies happened to be much stronger in general—not just their CAPA process. Is this a coincidence?

No, the CAPA process is how you correct and prevent quality problems. In order to find preventive actions you actually have to develop your other quality system processes. These companies have strategically chosen to develop their quality systems to a higher level of performance, because they know that preventing quality problems results will cost substantially less than waiting until problems occur, and then fixing those problems. These companies often talk about the “Cost of Quality,” and when you tour their facility, you see quality objectives being communicated to everyone.

I have only had a couple of clients in the past decade that argued about the importance of preventive actions, but most clients ask me, “Where can we find more?”

Guidance Documents

As a certification auditor, I was not allowed to “consult,” but was able to mention guidance documents that might help. Therefore, the number one guidance document I recommend is 13485 Plus (a document sold by the Canadian Standards Association – http://bit.ly/ShopCSA).

13485 Plus includes all Clauses of the 13485 Standard, including text from ISO 14969—an international guidance document for the implementation of ISO 13485. In section 8.5.3 of the guidance document, you will find the following list of preventive action sources:

  1. Purchased product rejected on receipt
  2. Evidence that previous decisions affecting product conformity were false
  3. Products requiring rework
  4. In-process problems, wastage levels
  5. Final inspection failures
  6. Customer feedback,
  7. Warranty claims,
  8. Process measurements,
  9. Statistical process control documents,
  10. Identification of results that are out-of-trend, but not out-of-specification,
  11. Difficulties with suppliers,
  12. Service reports, and
  13. Need for concessions.
Practical Experience

In addition to the sources listed in guidance documents, there are three other sources that I personally recommend to consulting clients. One source is your internal audit process. Auditors verify conformity of processes, but internal auditors should also look for processes that are inefficient and need improvement. When auditors are performing a process audit, some process owners have difficulty identifying process metrics that are being tracked for each process. Auditors should be trained to follow the audit trail when there is an absence of process monitoring, because processes that are not already measured usually have more room for improvement than processes currently being measured.

Another source of preventive actions is the Total Product Lifecycle Database on the FDA website (http://bit.ly/FDATPLC). Every three-letter product code has a corresponding database report that you can use to identify product malfunctions and adverse events associated with competitor products. Learning from the mistakes of your competitors and implementing appropriate preventive actions internally is a great way to avoid the need for corrective actions—especially for design malfunctions.

The most fruitful source of preventive actions, however, is data analysis of process control monitoring. This source can identify negative trends within your company’s manufacturing process and suppliers’ processes. Catching a negative trend before products and components are nonconforming reduces the number of corrective actions needed, cost of scrap or rework, and eliminates delays that result in customer complaints.

Setting a CAPA Quality Objective

As your company begins to develop additional sources of preventive actions, you may want to consider establishing a Quality Objective for your CAPA process. The most common Quality Objectives for a CAPA process are:

  1. Initiate at least one new preventive action per quarter
  2. Close all CAPAs within 90 days
  3. Reduce the average aging of CAPAs to <45 days

However, I would like to suggest another possible Quality Objective:

  1. Increase the ratio of preventive actions to corrective actions to > 1.00

To be successful in achieving this Quality Objective, you will need to increase your preventive actions and decrease the number of corrective actions. Reduction of corrective actions indicates that you are identifying potential problems before a corrective action is required, while the increase in preventive actions indicates that your process for identifying potential problems is becoming more effective.

%name Where to Locate Preventive Action Sources

If you are interested in learning more about preventive action, please register for the Medical Device Academy’s CAPA Workshop on September 9 in Orlando, or on October 3 in San Diego. Click here to register for the event: http://bit.ly/MDAWorkshops.

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Root cause analysis – Learn four different investigation tools

The author describes four tools (Five Why Analysis, Is/Is Not Analysis, Fishbone Diagram and Pareto Analysis) and how each one can help conduct effective root cause analysis.

5 why analysis for root cause analysis 1024x700 Root cause analysis   Learn four different investigation tools

Quality problems are like weeds. If you don’t pull them out by the root, they grow right back.

Root Cause Analysis Training

Most companies are doomed to repeat their mistakes, because the root cause for their mistakes is not fixed. Why don’t companies fix their mistakes? Because the people responsible for the corrective actions, (CAPA), were not adequately trained on root cause analysis. Adequate training on root cause analysis requires three things:

  1. Courage to admit that your process is broken
  2. Learning more than one tool for analyzing problems
  3. Practicing the use of root cause analysis tools

If your auditor identifies a nonconformity and you disagree with the finding, then you should not accept the finding and state your case. If an inspector rejects a part and you believe the part is acceptable, then you should allow the part to be used “as is.” In both of these cases, however, you need to be very careful. Sometimes the problem is that “acceptable” is not as well-defined as we thought. I recommend pausing a moment and reflecting on what your auditors and inspectors are saying and doing. You may realize that you caused the problem.

Once you have accepted that there is a problem, you need to learn how to analyze the problem. There are five root cause analysis tools that I recommend:

Root Cause Analysis Tool # 1 – 5 Why Analysis

A “Five Why Analysis” is not just five questions that begin with the word “why.” Taiichi Ohno is credited with institutionalizing the “Five Why Analysis” at Toyota as a tool to drill down to the root cause of a problem by asking why five times. I have read about this, used this tool, and taught this concept to students; but I learned of a critical instruction that I was missing when I read Toyota Under Fire.

In that book, Jeff Liker makes the following statement, “Toyota Business Practices dictates using the ‘Five Whys’ to get to the root cause of a problem, not the ‘Five Whos’ to find a fire the guilty party.” At the end of the book, there are lessons learned from Toyota’s experience. Lesson 2 says, “There is no value to the Five Whys if you stop when you find a problem that is outside of your control.” If your company is going to use this tool, it is important that the responsible person is the one performing the five why analysis, and asks why they didn’t take into account forces that are out of their control.

Root Cause Analysis Tool # 2 – Is/Is Not Analysis

The next tool was presented to me at an AAMI course that I attended on CAPA. One of the instructors was from Pathwise, and he explained the “Pathwise Process” to us for problem-solving. A few years later, I learned that this tool is actually called the “Is/Is Not Analysis.” This tool is intended to be used when you are having trouble identifying the source of a problem. This method involves asking where the problem is occurring as a potential clue to the reason for the problem. For example, if the problem only occurs on one machine, you can rule out a lot of possible factors and focus on the few that are machine-specific.

The reverse approach is also used to help identify the cause. You can ask where the problem is not occurring. This approach may also lead you to possible solutions for your problem. For example, if the problem never occurs on first or second shift, you should focus on the processes and the people that work on the third shift to locate the cause. The “Is/Is Not Analysis” is seldom used alone, but it may be the first step toward locating the cause of a quality problem.

Root Cause Analysis Tool # 3 – Fishbone Diagram

fishbone Root cause analysis   Learn four different investigation tools

This name comes from the shape of the diagram. Other names for this diagram are: the “Cause and Effect” or “Ishikawa”diagram. If a problem is occurring in low frequency and has always existed, this might not be your first tool. However, I typically start with this tool when I am doing an investigation of nonconforming product—especially when rejects suddenly appear.

If you are totally baffled about the cause of a problem, brainstorming the possible causes in a group sometimes works. However, I like to organize and categorize the ideas from a brainstorming session into the “6Ms” of the Fishbone Diagram.

Root Cause Analysis Tool # 4 – Pareto Analysis

The fourth root cause analysis tool is the Pareto Analysis–named after Antoine Pareto. This tool is also a philosophy that was the subject of a book called The 80/20 Principle: The Secret to Achieving More with Less. The Pareto Analysis is used to organize a large number of nonconformities and prioritize the quality problems based upon frequency of occurrence. The Pareto Chart presents each problem in descending order from the highest frequency to the lowest frequency. After you perform your Pareto Analysis, you should open a CAPA for the #1 problem, and then open a CAPA for the #2 problem. If you get to #3, consider yourself lucky to have the time and resources for it.

If you are interested in learning more about root cause analysis and actually practicing these techniques, please register for the Medical Device Academy’s Risk-Based CAPA training.

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A3 Reports – The Missing Link to Effective CAPA Process Management

A3 Workbook A3 Reports – The Missing Link to Effective CAPA Process ManagementYour CAPA process is the most important process in your Quality System for two reasons. First, CAPA is the tool you use to fix quality problems. Second, your CAPA process is guaranteed to be an area of interest for your next FDA inspector.

If CAPA is so important, why do companies still have ineffective CAPA processes?

When auditors review a CAPA process, some of them start by reading the procedure. When FDA writes a 483 observation about CAPA processes, the wording begins with “Procedures for corrective and preventive action have not been adequately established. Specifically…”. The approach of auditors and inspectors seems to suggest that your procedure is the key to an effective CAPA process, but your procedures are not the reason for success or failure of processes.

Processes are effective when management of the processes is effective. If a CAPA falls behind schedule, writing a justification for an extension is a process “solution.” A real solution is managing the process better. Management needs to monitor the progress of CAPAs on a regular basis, should prioritize resources to ensure that CAPAs are completed on time, and needs to make decisions on which actions should be taken to prevent recurrence of quality problems. Therefore, you need to spend more time developing a method of managing CAPAs than you spend developing the CAPA process itself.

What is an A3 Report?

An A3 report is a tool that is ideally suited for managing CAPAs. “A3” refers to the size of the paper used (i.e., – approximately 11”x17”). An A3 report is a one-sided, single piece of paper that is used to build consensus among company management when you are making an important decision. The initial draft of the A3 report is distributed to each of the affected departments to ensure that all possible inputs to a quality problem are received. By encouraging 360-degree feedback for a proposed solution to a quality problem, you will ensure that the CAPA you develop addresses the issue completely.

In addition to encouraging 360-degree feedback an A3 report includes an analysis of the problem, identification of the cause, proposed actions which require management decision, a section for documenting actions taken and a follow-up section for management to review at specific milestones during the implementation plan. Including all of this information in one page forces CAPA owners to summarize information for management, and the standardized format makes it easier for managers to locate the information they want.

Here’s how these sections would be used for managing CAPAs.

Analysis of the Problem

This section is identical to the section of a traditional CAPA record, where the investigation of the problem is documented. This is where tools such as 5 Why analysis, Pareto charts and Fishbone Diagrams would be used to illustrate the analysis of the problem. This section may change a great deal during the 360-degree review of the A3 report.

Root Cause or Potential Cause

In this section, there should be a concise statement of the root cause for corrective action plans, or the potential cause(s) for preventive action plans. During the initial review of the A3 report, management may ask the person or team assigned to the CAPA to investigate the problem in greater depth, or investigate other possible sources of information if the analysis appears to be inadequate. Management should also ensure that the causes are within the control of the company to correct or prevent. Identifying a cause that is outside the control of the company is just placing blame.

Proposed Actions

This section is similar to a typical CAPA plan, but the section includes the reason(s) why the proposed actions are recommended. The reasons why actions are proposed is important during the process of management reviewing the initial A3 report and approving the recommended actions. Best practice is to phrase the reasons in terms of quantitative results that will be achieved, because this will provide a framework for metrics during follow-up by management.

Actions Taken

This section of the A3 report is updated throughout the implementation of the project. By comparing this section with proposed actions, management can monitor the status of each task included in the CAPA plan.

Follow-up

This section of the A3 report identifies how management will monitor the implementation of actions and when. The initial A3 report identifies what management will be monitoring, how it will be monitored and at what milestones. Ideally, the monitoring includes quantitative metrics that demonstrate effectiveness of the CAPA. During implementation of the CAPA plan, actual metrics will be recorded in this section, and any adjustments that management makes are recorded here.

If you are interested in learning more about A3 reports, you can learn more from Daniel Matthews at: http://bit.ly/A3Workbook.

You can also learn more about improving your CAPA process by attending one of the workshops on CAPA: September 9 in Orlando or October 3 in San Diego. Each workshop is one day, and early bird pricing is $249 per day if you register prior to August 1. Click Here to learn more: http://bit.ly/12AxxQ0

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CAPA Advice – 15 Tips for Creating an Effective CAPA Form

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This blog reviews 15 tips for creating an effective CAPA form, including CAPA source, description of issue, investigation of root cause, and more.

CAPA Form 1024x362 CAPA Advice   15 Tips for Creating an Effective CAPA Form

The reason for creating a “great CAPA form” is to improve the effectiveness of your CAPA process. Anyone in your company could be assigned to a CAPA, but not everyone is a CAPA expert. Therefore, designing an effective CAPA form can reduce errors and improve effectiveness of the actions taken. You can also purchase our CAPA procedure and CAPA form which is compliant with ISO 13485:2016.

Corrective and Preventive Action CAPA Procedure CAPA Advice   15 Tips for Creating an Effective CAPA Form
Corrective and Preventive Action (CAPA) Procedure/Form

The CAPA procedure is a 4-page procedure which includes a CAPA form, and CAPA log. The procedure is compliant with ISO 13485:2016 and 21 CFR 820.100.

Price: $299.00

Provide adequate space in CAPA form

The most important feature of a CAPA form is to ensure that there is adequate space for writing a complete response for each section. Having adequate space is more important than the benefits of a shorter record.

Date your CAPA form was initiated

The date your CAPA form begins to be completed can be used to verify that there was not “undue delay” in the initiation of a CAPA in response to internal audit findings. The date of initiation is also used to calculate the due date for completing the investigation and providing a corrective/preventive action plan.

Include a cross-reference number in your CAPA form

This is typically a sequentially assigned CAPA log number. Ensure the number is prominent on all pages—just in case pages are separated.

CAPA source

The source of a CAPA is useful information when performing data analysis—especially for internal audits where the audit schedule should reflect results of previous audits. Examples of CAPA sources include:

  • Complaints/Reportable Events
  • Internal, Supplier and Third-Party Audits
  • Service Work Orders
  • Nonconforming Materials
  • Management Reviews

Description of CAPA issue

I use the word “issue” instead of nonconformity, because you need a CAPA form that will work for potential nonconformities (i.e., – preventive actions), as well as nonconformities. Typically, the wording is identical to a customer complaint or an auditor’s wording, but the description of the issue identifies the symptoms observed. Specific references to records, locations, times, equipment, products and personnel involved may be important to the root cause investigation.

Investigator assigned / target due date for plan

In ISO 13485:2016, the only change to the requirements for corrective actions and preventive actions was the clarification that planning is required. Since this was always implied in the standard, your procedure should already comply with clauses 8.5.2 and 8.5.3 in the 2016 version of ISO 13485.

This section of your CAPA form should identify who is going to investigate the root cause of the issue and the date that a corrective/preventive action plan is needed. The FDA requires submitting a corrective action plan for all 483 observations within 15 business days, or it will result in an automatic Warning Letter. Most certification bodies require a plan within 30 days. Your target due date should be risk-based, unless there is a specific regulatory requirement. The date will also need to be based upon the date the issue was identified—not necessarily the date the CAPA was initiated.

Investigation of Root Cause

This section always reminds me of the story about the Ohno Circle. Every company asks if they can close a nonconformity during an audit, and the answer should always be “No.” You can correct a problem, but you cannot perform a root cause investigation and implement an effective corrective action during the same audit. You need to investigate the cause and the investigation documented. Some companies include a specific tool in this section, such as a “Fishbone Diagram.” This is also a mistake, because there are many root cause analysis tools and you need to select the best one for your specific situation. You might even need to use more than one tool.

Containment of nonconforming product

If the issue requires preventive action, there is nothing to contain. If the issue is specific to a procedure’s deficiency, there is also nothing to contain. If the issue requires corrective action, and nonconforming materials or product are involved, then you need to quarantine the affected items. If affected product has already left the company’s direct control (see 21 CFR 806.2(l) for a definition), then you have a potential recall. Regulators often look for “bracketing” or “bounding” of the upper and lower lot limits for an issue. Therefore, this section is where you document the rationale for why certain lots of product/materials are quarantined and other lots are not.

Correction(s)

Fixing the immediate problem does not prevent recurrence, but regulators will verify that each occurrence of the issue identified during the investigation of root cause has been corrected. You need should verify that each of the nonconformities identified in the original finding and the investigation are addressed in this section of your CAPA form. For preventive actions, this section is not applicable.

Corrective Action Plan/Target Due Date for Implementation

These are the steps planned to prevent recurrence. If the plan changes, then it should be updated. There is no need to delete the old version of the plan, but the new version should clearly include a date when the plan was revised. For preventive actions, this section is not applicable. The target date of implementation should reflect the risk associated with the issue.

Preventive Action Plan/Target Due Date for Implementation

These are the steps planned to prevent occurrence of a nonconformity. If an issue occurred for one product, but not for others, the actions taken for other products can be preventive. In this case, both the corrective action plan and the preventive action plan sections should be completed. The target date of implementation should reflect the risk associated with the issue.

Corrective and Preventive Actions Implemented

This section details what specific actions were performed—both corrective and preventive actions can be documented here. The dates of completing actions should be documented and reasons for delays and overdue actions should be identified.

Plan for Verification of Effectiveness

I recommend filling this section in before the plan for corrective and preventive action is developed. This often helps the person developing the plan ensure that actions planned are adequate. Whenever possible, this should be quantitative, and it helps to identify a specific date for performing the effectiveness check.

Verification of Effectiveness

This section of your CAPA form is where you document verification of effectiveness. Specifically, what verification activities were performed in order to ensure that the corrective and preventive actions you implemented were effective. The date verification of effectiveness was performed should be documented, and if the actions were not effective, then a new CAPA should be referenced here.

Signature and Closure Date

It is important for someone to review, sign and date your CAPA form when it is completed. Often, regulators will review only closed records.

 

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CAPA Training Remediation Case Study: Hundreds of Open CAPAs

This blog presents a CAPA training case study related to hundreds of open CAPAs, and how to effectively remediate this issue using a CAPA filter to avoid “death by CAPA.”

Years ago, when I took my first CAPA course, the student sitting next to me explained that he was taking the course as part of a consent decree with the USFDA. Evidently. his company had hundreds of open CAPAs that were not being closed in a timely manner, and the CAPAs were ineffective when the records were finally closed.

Hundreds of open CAPAs?!

I was in total shock. You probably only have five to ten open CAPAs at your company. How could anyone have hundreds open?

He told me that every time a customer asked for technical support, a person was paged. If the page was not answered within three minutes, this was considered a customer complaint and a new CAPA was opened automatically. The course instructor described the situation as “Death by CAPA.” His company did three things wrong    

1. Overreaction with Microscopic Focus

The company incorrectly identified failure to meet the three minute target response time as a customer complaint. Also, several complaints related to the same issue should not result in a CAPA specific to each complaint.

2. Lack of Management Oversight

Nobody was tracking how long CAPAs remained open. There were no actions taken when target completion dates were missed. There were no reports to management on the status of CAPAs, and the only time CAPAs were discussed in a meeting was at the annual Management Review meeting.    

3. Failure to Check Effectiveness

Instead of verifying that corrective actions were effective, the company verified that corrective actions were implemented. Most of the corrective actions involved “retraining” or “revising the procedure.”

For any process to work correctly, you need to ensure that the process has the capability to handle the volume. If one person is responsible for managing hundreds of CAPAs each year, the CAPA process will be ineffective. You need more resources or fewer CAPAs. My recommendation is to use a CAPA filter.

 

Capa funnel photo CAPA Training Remediation Case Study: Hundreds of Open CAPAs

A CAPA filter does two things. First, it sorts CAPAs into problem categories. For example, all the poor response times to pages should be one problem with one CAPA. Second, a CAPA filter sorts CAPAs according to risk. A response to a page within five minutes instead of three minutes results in a customer waiting longer. A customer receiving no response could have a more severe impact, especially if the customer is a diabetic that cannot seem to get their glucose monitoring device to work properly.

Trend Analysis

Therefore, response rates to pages should be a metric subject to monitoring and measuring—not necessarily a CAPA. You have a positive trend if the number of late responses is declining, and the average delay is steadily shrinking. In this case, there may be no need for a CAPA. You have a negative trend if the number of late responses is increasing, or the average delay is getting longer. In this case, one or two CAPAs may be needed—not one CAPA for each individual occurrence.

Depending upon the issue, there may be a safety issue associated with extreme limits. In this case, it is recommended to establish alert limits and action limits. Alert limits may increase the frequency of monitoring and measuring, and corrections may also be implemented. However, if the action limit is reached, then a CAPA may be required.

Quality Plan

When I audit a company, it is not uncommon to observe a problem and to quickly identify a root cause. This happens frequently when the problem is common to many companies and the root cause is: 1) inadequate procedures, 2) inadequate training, or 3) inadequate management oversight. If the problem is limited to one area, a CAPA may be completely appropriate. However, if I observe the same type of problems in several areas, then the root cause is systemic. This can happen in a company where the following problems exist at the same time:

  1. The training procedure does not require demonstrating training effectiveness
  2. Employees are only required to “read and understand” procedures
  3. Top management has put a “freeze” on spending related to training

In a small company, this trifecta of doom is not uncommon. Therefore, in these cases, a CAPA does not really address the root cause. Many companies will mistakenly identify the root cause as an “inadequate procedure.”  The correction will be to fix the problem caused by the inadequate procedure. The corrective action will be to revise the procedure.

This is only a partial solution, because it does not address the root cause. A stronger approach is to identify the root cause as an “ineffective training process.” The correction will be the same. The corrective action, however, will be expanded to include initiation of a Quality Plan for changing the company training process.

The combined approach of a CAPA plan and a Quality Plan is a better solution, because the process change will affect the entire Quality Management System and will require many months to fully implement. This is especially true if resources are constrained.

Here are a couple of upcoming webinars I am doing on CAPA and Complaint Handling:

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