1. Quality Management System Corrective and Preventive Actions Argenis Osorio – Manager, Quality Assurance 19 September 2013 FACULTY MANAGEMENT

2. Corrective and Preventive Actions  Purpose and Scope — This procedure defines the roles, responsibilities and the process of handling corrective and preventive actions across Facilities Management at the University of Calgary, all while continually improving the Quality Management System. 2

3. Corrective and Preventive Actions  What is a Corrective and Preventive Action? — Corrective actions are steps performed to eliminate the cause of a detected non-conformance, thereby eliminating its possible re-occurrence. A Corrective Action Report (CAR) will be initiated to address this type of non- conformance. — Preventive actions are steps performed to eliminate the cause of a potential non-conformance, thereby eliminating its possible occurrence. A Preventive Action Report (PAR) will be initiated to address this type of non-conformance. 3

4. Corrective and Preventive Actions  These two actions may be initiated due to issues typically arising from: — Customer complaint, — Quality system audit (internal and external), — Supplier performance monitoring, — Management reviews, — Customer feedback, — Employee observation, and — Non-conformance. 4

5. Corrective and Preventive Actions  Responsibilities of Managers/Supervisors/Employees — Managers / Supervisors:  Ensuring the assignment of resources needed for the timely completion of all CARs and PARs that are assigned to their department, and  Ensuring their staff report and document all non- conformances. — Employees:  Submit a preventive or corrective action request to their supervisor when they identify a non-conformance or a potential non-conformance. 5

6. Corrective and Preventive Actions 6

7.  The escalation process for any CAR/PAR open beyond the stated due date shall be as follows: — At the due date, the actionee and their immediate manager will be notified that the CAR/PAR due date has been reached and has not been closed. — CARs/PARs remaining open for more than 15 calendar days past their due date will be escalated to the actionee’s Director and to the Manager, Quality Assurance. — Any CARs/PARs remaining open for more than 30 calendar days past their due date will be escalated to the actionee’s AVP and to the Manager, Quality Assurance. — Any CARs/PARs remaining open for more than 60 days past their due date will be escalated to the actionee’s AVP and to the VP, Facilities Management and Development. 7

8. Corrective and Preventive Actions  Root Cause Analysis Tools — Ishikawa / Fishbone / Cause and Effect Diagram 8

9. Corrective and Preventive Actions  Root Cause Analysis Tools - Continued — 5 Whys is an interactive question-asking technique used to explore the cause-and-effect relationships underlying a particular problem. — Example: — The vehicle will not start. (the problem)  Why? - The battery is dead. (first why)  Why? - The alternator is not functioning. (second why)  Why? - The alternator belt has broken. (third why)  Why? - The alternator belt was well beyond its useful service life and not replaced. (fourth why)  Why? - The vehicle was not maintained according to the recommended service schedule. (fifth why, a root cause)  Why? - Replacement parts are not available because of the extreme age of the vehicle. (sixth why, optional footnote) — Start maintaining the vehicle according to the recommended service schedule. (possible 5th Why solution) — Adapt a similar car part to the car. (possible 6th Why solution) 9