When we start talking about deviations and CAPAs, we can’t help having a sidebar discussion about root causes and more specifically the rant about finding the true root cause. I intentionally skipped that content in the previous blog. It was my intention to kick off the new Deviation and CAPAs blog series by first looking at deviations by themselves. And the learning opportunities deviations can provide us
Corrective Actions Preventive Actions (CAPA) Steps
Let’s step back a moment and quickly review typical steps for CAPAs:
The purpose of an Effectiveness Check (EC) is for verifying or validating that actions taken were effective and do not adversely affect product, device or process. It goes beyond the statement in the investigation form to include a follow-up activity that closes the loop on the specific CAPA.
If an effectiveness check fails, meaning the CA/PA was not effective or another deviation /nonconforming incident has occurred, we go back to the beginning and either start again or in most cases, we re-open the investigation. The pressing question is why did the EC fail? Almost instinctively, we believe that we did not find the true root cause. Perhaps.
Was there a rush to close the investigation? Probably.
Did the investigation team grab the first probable cause as the root cause because the “problem” felt familiar? Maybe.
Or is it a case of a fix that backfired into unintended consequences? Possibly. I will also suggest that the CA/PA may not have been aligned properly.
Ask these 3 questions about CA/PAs
- Is the CA/PA Appropriate? The focus of this question is about the affected people. What is the size of this audience? Is it mainly one person or groups of people?
Can the CA/PA be executed efficiently? Is it for one site or multiple sites?
- Is the CA/PA Economical? What budget is available?
Is it a “cheap” fix or a 3 – 6 month project? Or an expensive solution of more than 6 months and will need capital expenditure funding?
- Is the CA/PA Feasible? The real question is about the timeline.
Need it fast – within 3 months or
Have time – don’t need until more than 3 months from now.
And then there is the unspoken 4th question – is the CA/PA “political”? I experienced first hand what happens to CAPAs that are politically oriented. Most of them failed their ECs. Request “Can You Stay a Little While Longer”. The best CAPAs are the ones that map back to the root cause.
Introducing the HPISC CAPA Performance Chain
On the left-hand side, you will recognize the 3 traditional tasks to complete. After the EC is written, trace upwards to ensure that the EC maps back to the CA/PA and that the CA/PA maps back to the root cause; hence, the bottom-up arrow. On the right-hand side are performance improvement activities that I use as a Performance Consultant (PC) to bring another dimension to the CAPA investigation, namely, Human Performance Improvement (HPI).
Before I can write the root cause statement, I examine the “problem” also known as a Performance Discrepancy or an incident and I conduct a Cause Analysis that forces me to take a three tiered approach (the worker, the work tasks, the workplace) for the possible causes and not get bogged down in observable symptoms only.
The Performance Solution is more appropriately matched to the identified gap. In theory, this is what the corrective action(s) is supposed to do as well. During the performance solution planning, determination of success and what forms of evidence will be used happens with key stakeholders. So that collecting the data happens as planned, not as an afterthought, and the effectiveness is evaluated as discussed.
What can we really control?
In RCA/CAPA meetings, I often hear about what management should do to fix the working conditions or how most of the operator errors are really managements’ fault for not taking the culture factor seriously enough. While there may be some evidence to back that up, can we really control, reduce or eliminate the human factor? Perhaps a future blog on understanding human errors will be released.
- Design work situations that are compatible with human needs, capabilities and limitations
- Carefully match employees with job requirements
- Reward positive behaviors
- Create conditions that optimize performance
- Create opportunities to learn and grow professionally.
Clues for Failed Effectiveness Checks
One of the first activities to perform for a failed EC is to evaluate the effectiveness check statement. I have read some pretty bizarre statements that challenge whether the EC was realistic to achieve at all. The conditions under which we expect people to perform must be the same as the conditions we evaluate them during an EC review. So why would we set ourselves up to fail by writing ECs that don’t match normal workplace routines? What, because it looked good in the investigation report and it got the CAPA approved quicker?
Next, trace back each of the CAPA tasks to identify where to begin the re-investigation. I also suggest that a different root cause analysis tool be used. And this is exactly what we did while I was coaching a cohort of Deviations Investigators.
Future blogs will discuss RCA tools in more detail. -VB
Did you know that Vivian teaches 3 courses on Human Errors?
(c) HPIS Consulting, Inc.