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Purpose
•	Reduce waste and mistakes
•	Maintain our clients and customers’ quality requirements
•	Improve existing work procedures
•	Increase our efficiency and our profitability
•	Add value to our procedures and processes.

When we identify:	We will:	
[preventive action]	detect, analyse, and eliminate potential causes of nonconformance.	
[improvements]	Identify and record suggestions and improvements into the business	
[nonconformance]	identify, segregate, document, repair and dispose of nonconformance;	
[corrective action]	take prompt corrective actions to meet quality requirements, eliminate nonconformance, and prevent recurrence;	
[more..]	[more..]	

Background
This procedure in many ways forms the core of the management system.
It provides a process for capturing and acting upon system breakdowns and all of the necessary process updates and improvements that any vibrant organisation will identify from time to time.
This is a system of continuous improvement that is central to the well being of any organisation.
It is vital that this process take place in an atmosphere where accountability and responsibility for fixing or acting on the matter is taken but there is no blame attaching.

REMEMBER:  any business that is not evolving is dissolving! 

Scope
All Staff

Procedure
Reporting complaints, issues and problems
No.	TYPE	CORRECTIVE ACTION	
1.	SUPPLIER PROBLEMS – minor, eg late delivery, packaging problems.	Fix by phone call to supplier.
	
2.	SUPPLIER PROBLEMS – quantity problems, eg short shipped, incorrect items.	Fix by phone call to supplier. Consider status of supplier on supplier register	
3.	CLIENT COMPLAINTS – minor, no long-term significance.	Deal with immediately/promptly.
Advise (WHO?), record in Complaints Register (consider CAR Form)	
4.	CLIENT COMPLAINTS – serious or significant.	Deal with immediately and urgently.
Record in Complaints Register.
CAR Form filled out and passed to Quality Manager.
(Management) advised immediately.	
5.	STAFF RELATIONS ISSUES	Attempt to resolve in a private meeting between the parties if appropriate, manager may need to act as a mediator.  If endemic and sufficiently serious raise at Management Meeting.	
6.	OPPORTUNITIES & SUGGESTIONS – 
Where improvements are identified
Efficiency can be improved
Waste minimised.	Raise at relevant Meeting.	
7.	INTERNAL AUDITS
Nonconformance or significant issues identified during an Internal Audit.	If warranted, or useful to do so, raise a specific CAR Form, so that the issues can be dealt with separately.	
8.	Consider other issues that you may wish to address specifically here.		

Using Corrective Action Required (CAR) forms
All Staff are to be trained and encouraged in the use of CAR Forms.

Staff:
•	Enter details on form
•	Pass form to the Quality Manager.

(Discuss at staff meeting, if appropriate)

Quality Manager to:
•	Process promptly
•	Identify underlying or root causes, and note on CAR Form
•	Proceed with corrective and preventive actions, and note on CAR Form
•	Enter CAR on CAR Log
•	Maintain open/closure status on Log
•	Follow-up outstanding open CARs
•	Present Log to Manager at Monthly Management Meeting
•	Make changes to procedures, forms and management system as required by corrective and preventive actions.

Manager:
•	Reviews and approves major CAR actions at Monthly Meeting.

Corrective action
Corrective action procedures will include the need to:
•	Act quickly.
•	Identify the cause of the problem
•	Notify relevant stakeholders
•	Determine appropriate action.
•	Re-inspect after CAR Action
•	Record all corrective actions on the CAR Form
•	Ensure the corrective actions eliminate the problem
•	Review and amend current procedures, documents and forms relevant to the nonconformance
•	Re-train Staff where procedures have been changed.

CAR Management 
•	Complaint/Corrective Action/Suggestion for Improvement received
•	Is this a major or minor matter (see below for definitions)
o	if minor matter, deal with it immediately and note on CAR Log only
•	If major take immediate appropriate action to address the concerns of the parties involved.
•	complete the top section of the CAR Form and raise for discussion at appropriate meeting (Staff Meeting or Management Meeting)
•	Pass the form to the (Quality Manager) for action
o	(Quality Manager) identifies the root cause of the CAR
•	(Quality Manager) in conjunction with senior management (if appropriate) either delegates or proceeds with corrective action.
o	CAR is entered to CAR log and status on Log maintained until completed.
o	CAR Log is presented to Monthly Management Meeting
o	Major CAR's are identified at regular staff meeting.
•	Outcomes of this process can include further staff training as necessary
•	(Quality Manager) reviews CARs regularly to ensure that the corrective action taken has been effective in eliminating the cause of the CAR.
•	Once CAR form and actions completed, enter close out details to CAR log
•	A procedure change may be required to rectify causes of CAR

Definition of Major and Minor CAR
Major CARs include:
•	Complaints which have legal and or financial impacts or which might impact upon the reputation of our business.

Minor CARs include:
•	Complaints which have minimal or low impact and are easily resolved with no long term effects.

Preventive action
All staff should routinely source information and discuss methods to eliminate potential causes of nonconformance.

These can be discussed at management meetings, and may include (amongst others):
•	keeping up to date with industry changes and new procedures
•	review of regulations and codes of practice
•	better use of procedures and checklists
•	attending management and industry training courses
•	surveying consultants, clients and customers to gain feedback
•	maintaining a “Best Practice” program

Manager regularly reviews all suggestions etc.