In this article, you will learn how to get ISO 13485 certified, and you will be successful while avoiding the stress that tortures other quality managers.
There is a big difference between being ISO 13485 certified and being compliant with ISO 13485:2016, the medical devices quality management systems standard. Anyone can claim compliance with the standard. Certification, however, requires that an accredited certification body has followed the requirements of ISO 17021:2015, and they have verified that your quality system is compliant with the standard. To maintain that certification, you must maintain your quality system’s effectiveness and endure both annual surveillance audits and a re-certification audit once every three years.
Step 1 – Planning for ISO 13485 certification
There are six steps in the ISO 13485 certification process, but that does not mean there are only six tasks. The first step in every quality system is planning. Most people refer to the Deming Cycle or Plan-Do-Check-Act (PDCA) Cycle when they describe how to implement a quality system. However, when you are implementing a full quality system, you need to break the “doing” part of the PDCA cycle into many small tasks rather than one big task. You also can’t implement a quality system alone. Quality systems are not the responsibility of the quality manager alone. Implementing a quality system is the responsibility of everyone in top management.
Below you will find seven tasks listed. I did NOT identify these nine tasks as “Steps” in the ISO 13485 certification process, because these tasks are typically repeated for each process in your quality system. Most quality systems are implemented over time, and the scope of the quality system usually grows. Therefore, you are almost certain to have to perform all of the following nine tasks multiple times–even after you receive the initial ISO 13485 certification. As the saying goes, “How do you eat an elephant? One bite at a time.” Therefore, avoid the inevitable heartburn caused by trying to do too much at one time. Implement your quality system one “bite” at a time.
Task 1 – Purchase applicable standards
The first task in implementing an ISO 13485 quality system is to purchase a copy of the ISO 13485:2016 standard, such as the MDSAP Companion Document. You will also need other applicable medical device standards. Some of these standards are general standards that apply to most, if not all, medical devices, such as ISO 14971:2019 for risk management. There are also guidance documents that explain how to use these general standards, such as ISO/TR 24971:2020, guidance on how to apply ISO 14971:2019. Finally, there are testing standards that identify testing methods and acceptance criteria for things such as biocompatibility and electrical safety. You will need to monitor these standards for new and revised versions. When these standards are updated, you will need to identify the revised standard and develop a plan for addressing the changes.
When you purchase a standard, be sure to buy an electronic version of the standard so you can search the standard for keywords efficiently. You should also consider purchasing a multi-user license for the standard because every manager in your company will need to look-up information in the standard. Alternatively, you could buy a paper copy of the standard and locate the standard where everyone in your company can access it. Often I am asked what the difference is between the EN version of the standard and the ISO version of the standard. “EN” is an abbreviation meaning European Standards or “European Norms,” which is based upon the literal translation from the French (i.e., “normes”) and German (i.e. “norm”) languages. “ISO” versions are international standards. In general, the body of the standard is typically identical, but harmonized EN standards for medical devices include annexes ZA, ZB, and ZC that identify any deviations from the requirements in three medical device directives (i.e., MDD, AIMD, and IVDD).
Task 2 – Identify which processes are applicable
Clause 1 of ISO 13485 is specific to the scope of a quality system. ISO 9001, the general quality system standard, allows you to “exclude” any clause from your quality system certification. However, ISO 13485 will only allow you to exclude design controls (i.e., clause 7.3). Other clauses within ISO 13485 may be identified as “non-applicable” based upon the nature of your medical device or service. You must also document the reason for non-applicability in your quality manual. Typically, the following clauses are common clauses identified for non-applicability:
- Clause 4.1.6 – quality system software
- Clause 6.4 – work environment
- Clause 7.5.2 – cleanliness of the product
- Clause 7.5.3 – installation
- Clause 7.5.4 – servicing
- Clause 7.5.5 – sterile devices
- Clause 7.5.6 – process validation
- Clause 7.5.7 – sterilization validation
- Clause 18.104.22.168 – implantable devices
- Clause 7.5.10 – customer property
- Clause 8.3.4 – rework
Task 3 – Assign a process owner to each process
The third task is to assign a process owner to each of the processes in your quality system. Typically, you create a master list of each of the required processes. Usually, the assignments are made to managers in the company who may delegate some or all of a specific process. You should expect most managers to be responsible for more than one process because there are 28 required procedures in ISO 13485:2016, but most companies have fewer than ten people when they first implement a quality system.
Task 4 – Prioritize and schedule the implementation of each process
The fourth task is to identify which processes need to be created first and to schedule the implementation of procedures from first to last. You can and should build flexibility into the schedule, but some procedures are needed at the beginning. For example, you need document control, record control, and training processes to manage all of your other procedures. You also need to implement the following processes to document your Design History File (DHF): 1) design controls, 2) risk management, 3) software development (if applicable), and 4) usability. Therefore, these represent the seven procedures that most companies will implement as early as possible. Procedures such as complaint handling, medical device reporting, and advisory notice procedures are usually reserved for last. These procedures are last because they are not needed until you have a medical device in use.
Task 5 – Create forms, flowcharts, and procedures for each process
Forms create the structure for records in your quality system, and a well-designed form can reduce the need for lengthy explanations in a procedure or work instruction. Therefore, you should consider developing forms first. The form should include all required information that is specified in the applicable standard or regulations, and the cells for that information should be presented in the order that the requirements are listed in the standard. You might even consider numbering the cells of the form to provide an easy cross-reference to the corresponding section of the procedure. Once you create a form, you might consider creating a flowchart next. Flowcharts provide a visual representation of the process. You might consider included numbers in the flow chart that cross-reference to the form as well.
Once you have created a form and a flowchart, you are now ready to write your quality system procedure. Many sections are typically included in a procedure template. It is recommended that you use a template to ensure that none of the basic elements of a procedure are omitted. You might also consider adding two sections that are uncommon to a procedure: 1) risk analysis of the procedure with the identification of risk controls to prevent risks associated with the procedure, and 2) a section for monitoring and measurement of the process to objectively measure the effectiveness of the process. These metrics are the best sources of preventive actions, and some of the metrics might be potential quality objectives to be identified by top management.
Task 6 – Perform a gap analysis of each procedure
Most companies rely upon internal audits to catch and missing elements in their procedures. However, audits are intended to be a sampling rather than a 100% comprehensive assessment. Therefore, when a draft procedure is being reviewed and approved for the first time, or a major re-write of a procedure is conducted, a thorough gap analysis should be done before the approval of the draft procedure. Matthew Walker created an article explaining how to conduct a gap analysis of procedures. In addition, Matthew has been gradually adding cross-references to ISO 13485:2016 requirements in each procedure. He is color-coding the cross-referenced clauses in blue font as well. This makes it much easier for auditors to verify that a procedure is compliant with the regulations with minimal effort. The success of these two methods has taught us the importance of conducting a gap analysis of all new procedures.
Task 7 – Train applicable personnel for each process
You are required to document the training requirements for each person or each job in your company. Documentation of training requirements may be in a job description or within a procedure. In addition to defining who should be trained, you also need to identify what type of training should be provided. We recommend recording your training to ensure that new future employees receive the same training. This will ensure consistency. You are also required to maintain records of the training. You must verify that training was effective, and you need to check the person is competent in performing the tasks. This training may require days or weeks to complete. Therefore, you may want to start training people several weeks before your procedure is approved. Alternatively, you can swap the order of tasks and conduct training after the procedure approval. If that approach is taken, then the procedure should indicate the date the procedure becomes effective–typical 30 days after approval to allow time for training.
Task 8 – Approve the procedure
Approval of a procedure may be accomplished by signing and dating the procedure itself, while another approach is to create a document that lists all the procedures and forms being approved at one time. The second method is the method we use in our turn-key quality system. Companies can review and approve as many procedures at one time as they wish. Since this process needs to be defined to ensure that all of the procedures you implement are approved, the document control process is typically the first procedure that companies will approve in a new quality system. The second procedure generally is for control of records. Then the next procedures implemented will typically be focused on the documentation of design controls: design controls, risk management, usability testing, and software development. The last procedures to be approved are typically complaint handling, medical device reporting, and recalls. These procedures are left for last because you don’t need them until you are selling your medical device.
Task 9 – Start using the procedure and generating records
The last task required for the implementation of a new quality system is to start using the procedures to generate records. All of the procedures will need records before the process can be verified to be effective. Records can be paper-based, or the records can be electronic. Whichever format you use for the record retention needs to be communicated to everyone in the company through your Control of Records procedure and/or within each procedure. If you include the information in each procedure, the records of each procedure should be listed in the procedure, and the location where those records are stored should be identified. Generally, there is no specific minimum number of records to have for a certification audit, but you should have at least a few records for each process that you implement.
Step 2 – Conducting your first internal audit
The purpose of the internal audit is to verify the effectiveness of the quality system and to identify nonconformities before the certification body auditor finds them. To successfully achieve this secondary objective, it is essential to have a more rigorous internal audit than you expect for the certification audit. Therefore, the internal audit should be of equal duration or longer in duration than the certification audit. The internal audit should not consist of a desktop review of procedures. Reviewing procedures should be part of gap analysis (i.e., task 6 above) that is conducted on draft procedures before they are approved. Internal audits should utilize the process approach to auditing, and the auditor should apply a risk-based approach (i.e., focus on those processes that are most likely to contribute to the nonconforming products, result in a complaint, or cause severe injuries and death).
After your internal audit, you will receive an internal audit report from the auditor. You should also expect findings from the internal auditor, and you should expect opportunities for improvement (OFI) to be identified. Experienced auditors can typically identify the root cause of a nonconformity more quickly than most process owners. Therefore, it is recommended for each process owner and subject matter expert to review nonconformities with the auditor and discuss how the nonconformity should be investigated. The root cause must be correctly identified during the CAPA process, and the effectiveness check must be objective to ensure that problems do not recur.
Step 3 – Initiating corrective actions
Corrective actions should be initiated for each internal audit finding immediately, to make sure the findings are corrected and prevented from repeat occurrence before the Stage 1 audit. It will take a minimum of 30 days to implement the most corrective actions. Depending upon the scheduling of the internal audit, there may not be sufficient time to complete the corrective actions. However, you should at least initiate a CAPA for each finding, perform an investigation of the root-cause, and begin to implement corrective actions.
Also, to taking corrective actions related to internal audit findings, you should look for internal audits from other sources. The diagram below shows several different sources of potential corrective and preventive actions.
Monitoring and measuring of each process is the best source of preventive actions, while internal audits are typically the best source of corrective actions. Any quality problems identified during validation are also excellent sources of corrective actions because the validation can be repeated as a method of demonstrating that the corrective actions are effective. However, your ISO 13485 certification auditor will focus on non-conforming products, complaints, and service as the most critical sources of corrective actions. These three sources are prioritized because these three sources have the greatest potential for resulting in a serious injury, death, or recall if corrective actions are not implemented to prevent problems from recurring.
Step 4 – Conducting your first management review
In addition to completing a full quality system audit before your stage 1 audit, you are also expected to complete at least one management review. To make sure that you have inputs for each of the 12 requirements in the ISO 13485:2016 standard, it is recommended to conduct your management review only after you have completed your full quality system audit and initiated some corrective actions. If possible, you should also conduct supplier audits for any contract manufacturers or contract sterilizers. It is recommended to use a template for that management review that is organized in the order of the required inputs to ensure that none of the necessary inputs are skipped. Quality objectives will need to be established long before the management review so that the top management team has sufficient time to gather data regarding each of the quality objectives. Also, you should consider delegating the responsibility for creating the various slides for each input to different members of top management. This will ensure that everyone invited to the meeting is engaged in the process, and it will spread the workload for meeting preparation across multiple people.
At the end of the meeting, top management will need to create a list of action items to be completed before the next management review meeting. Meeting minutes will need to be documented for the meeting, including the list of action items and each of the four required outputs of the management review process. We recommend using the notes section of a presentation slide deck to document the meeting minutes related to each slide. Then the slide deck can be converted into notes pages and saved as a PDF. The PDF notes pages will be your final meeting minutes for the management review. An example of one of these notes pages is provided in the figure below.
One of the more common non-value-added findings by auditors is when an auditor issues a nonconformity because you do not have your next internal audit and your next management review scheduled–even though each may have occurred only a month prior to the Stage 1 audit. Therefore, we recommend that you document your next 12-month cycle for internal audits and schedule your next management review as action items in every management review meeting. The schedule can be adjusted if needed, but this allows top management to emphasize various areas in internal audits that may need improvement. You might even set a quality objective to conduct a minimum of three management reviews per year at the end of your first management review.
Step 5 – Stage 1, Initial ISO 13485 Certification Audit
In 2006, the ISO 17021 Standard was introduced for assessing certification bodies. This is the standard that defines how certification bodies shall go about conducting your initial certification audit, annual surveillance of your quality system, and the re-certification of your quality system. In the past, certification bodies would typically conduct a “desktop” audit of your company before the on-site visit to make sure that you have all the required procedures. However, ISO 17021 requires that certification bodies conduct a Stage 1 audit that assesses the readiness of your company before conducting a Stage 2 audit. Therefore, even if the Stage 1 audit is conducted remotely, the certification body is expected to interview process owners and sample records to verify that the quality system has been implemented. Certification body auditors will also typically verify that your company has conducted a full quality system audit and at least one management review. Finally, the auditor will usually select a process such as corrective action and preventive action (CAPA) to make sure that you are identifying problems with the quality system and taking appropriate measures to address those problems.
Your goal for the Stage 1 audit should not be perfection. Instead, your focus is to make sure that there are no “major” nonconformities. The term “major” used to have a specific definition:
- Absence of a documented procedure or process
- Release of nonconforming product
- Repeat nonconformities (not possible during a Stage 1)
Under the MDSAP, the grading system for nonconformities now uses a numbering system for grading of nonconformities: “Nonconformity Grading System for Regulatory Purposes and Information Exchange Study Group 3 Final Document GHTF/SG3/N19:2012.” Any nonconformity is graded on a scale of one to four, and then two potential escalation rules are applied. If any nonconformities are graded as a four or a 5, then the auditor must assess whether a five-day notice to Regulatory Authorities is required. A five-day notice is required for in either of the following situations: 1) one or more finding grading of “5”; or 2) three or more findings graded as “4.” If your Stage 1 audit results in a five-day notice, then you are not ready for your Stage 2 audit. For example, a complete absence of two required procedures in clauses 6.4 through 8.5 of ISO 13485:2016 would result in two findings with a grading of “4.” This would not result in a five-day notice, but the absence of a third required procedure would result in a five-day notice.
The duration of your Stage 1 audit will be one or two days, but a 1.5-day audit is quite common for MDSAP Stage 1 audits. The reason for the 1.5-day Stage 1 audit is that it is challenging to assess readiness for Stage 2 in one day, and if the total duration of Stage 1 and Stage 2 is 5.5 days, then the Stage 2 audit could be completed in four days. The four-day audit is more convenient than a three-day audit for a two-person audit team.
After your Stage 1 audit, you will receive an audit report, and you should expect findings. You should initiate corrective actions for each finding immediately, to make sure the findings are corrected and prevented from repeat occurrence before the Stage 2 audit. The duration between the audits is typically about 4-6 weeks. That does not leave much time for you to initiate a CAPA, perform an investigation of the root-cause, and implement corrective action. At a minimum, you must submit a corrective action plan for each finding to your MDSAP auditing organization (AO) within 15 calendar days of receiving the finding. For any findings graded as a “4” or higher, you will need to provide evidence of implementing the corrective action plan to the AO with 30 calendar days of receiving the finding. You are also unlikely to have enough time to conduct an effectiveness check prior to the Stage 2 audit.
Step 6 – Stage 2, Initial ISO 13485 Certification Audit
The Stage 2 initial ISO 13485 certification audit will verify that all regulatory requirements have been met for any market you plan to distribute in. The auditor will complete an MDSAP checklist that includes all of the regulatory requirements for each of the countries that recognize MDSAP: 1) the USA, 2) Canada, 3) Brazil, 4) Austria, and 5) Japan. The auditor will also sample records from every process in your quality system to verify that the procedures and processes are fully implemented. This audit will typically be at least four days in duration unless multiple auditors are working in an audit team.
The audit objectives for the Stage 2 ISO 13485 certification audit specifically include evaluating the effectiveness of your quality system in the following areas:
- Applicable regulatory requirements
- Product and process-related technologies
- Technical documentation
All procedures will be reviewed for compliance with ISO 13485:2016 and the applicable regulations. The auditor will also sample records from each process. If the auditor identifies any nonconformities during the audit, it is important to record the findings and begin planning corrective actions immediately. If you have any questions regarding the expectations for the investigation of the root-cause, corrections, corrective actions, and effectiveness checks, you should ask the auditor during the audit or the closing meeting. At a minimum, you must submit a corrective action plan for each finding to your MDSAP auditing organization (AO) within 15 calendar days of receiving the finding. For any findings graded as a “4” or higher, you will need to provide evidence of implementing the corrective action plan to the AO with 30 calendar days of receiving the finding. The auditor will not be able to recommend you for ISO 13485 certification until your corrective action plans are accepted.
If you receive a finding with a grading of “5,” or three or more findings graded as “4,” then the MDSAP auditor is required to issue a five-day notification to the regulators. The auditor will also need to return to your facility for a follow-up audit to close as many findings as they can. It is not necessary to eliminate all of the findings in order to be recommended for ISO 13485 certification, but the grading of the findings must be reduced to at least a “3” before recommending the company for certification. The number of findings also determines whether the auditor recommends your company for certification.
In addition to reviewing the findings and conclusions of the audit during the closing meeting, the auditor will also review the plan for the annual surveillance and re-certification with you. Each certification cycle is three years in duration. There will be two surveillance audits of approximately one-third the duration of the combined duration of stage 1 and stage 2 initial certification audits, and the first surveillance audit must be completed within 12 months of the initial certification audit. In the third year, there will be a re-certification audit for two-thirds of the duration of the combined duration of stage 1 and stage 2 initial certification audits. The initial ISO 13485 certificate will be issued with a three-year expiration, and the certificate is typically received about one month after the acceptance of your corrective action plan.