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Wessex CQI Branch Meeting Thursday 16 th February 2012 Jim Kirk FCQI CQP Slide 2 CQI Wessex Branch How can you get people to close NCR's and complete actions from System Review meetings? Contributors Andy NicholsPaul Palmer Duncan Dando Moira BigginsMark Braham David SmartKar-Wing LauIan DallingDavid HoyleJennie Clark Steve Brocklehurst Noel ClarkeNeil Mellor John Symonds Jim Kirk Slide 3 CQI Wessex Branch Linked In Discussion 29 Comments! Slide 4 CQI Wessex Branch What are actions? (1) actions that people see are valuable to their work, and genuinely intend to do, but just haven't done yet (2) actions that people see are valuable to their work, but don't have the resources to address (3) actions that people don't see as being valuable to their work, but regard as a box-ticking exercise - and may try to avoid doing. Slide 5 CQI Wessex Branch Other Classifications Effective busy people tend to categorise tasks in the following hierarchy, You may have seen this as a chart. 1. Very Important and Urgent - Do Now 2. Not So Important but Urgent - Do Later 3. Very Important but not Urgent - Do ASAP 4. Needed but Not Urgent - Do when there is a spare 5 minutes. 5. Not Required - Bin ! Slide 6 CQI Wessex Branch Chasing Methods Chasing methodPoints in Favor of Method Disadvantages Nagging emails Easy to carry out and may even be automated People will get overly used to these emails and treat them as spam and quickly delete them personal visit guilt feeling by the auditee Creates Nuisance Slide 7 CQI Wessex Branch Chasing methodPoints in Favor of Method Disadvantages KPIs Highlights to management when things are going in the wrong direction Only of any use if management take notice of NCR and Outstanding actions KPIs Chasing Methods Slide 8 CQI Wessex Branch Chasing methodPoints in Favor of Method Disadvantages Promote NCR from not important to Urgent This will make the actionee realize that he / she should to close out the action quickly The promotion to Urgent status will certainly not be justified for all NCRs or unclosed actions. This would dilute the effectiveness of this technique if used too frequently Chasing Methods Slide 9 CQI Wessex Branch Chasing methodPoints in Favor of Method Disadvantages Name and Shame Quickly produces a guilty feeling by the actionee and encourage quick closure This makes the whole NCR and closure of actions a negative situation and would cause increased alienation to the process making it harder not easier to get people to do what they are supposed to do in the future Chasing Methods Slide 10 CQI Wessex Branch Chasing methodPoints in Favor of Method Disadvantages Escalate to actionees boss, or his / her bosses superior, even to director level This would make the higher management realize what is going on in their department and encourage the manager to discipline staff in his / her department. This again would tend to have a negative effect to NCRs and action points and make it harder not easier to get buy in and co- operation Chasing Methods Slide 11 CQI Wessex Branch Chasing methodPoints in Favour of MethodDisadvantages Risk assessments and method statements are used extensively to control risks and hazards Clear indication as to the importance and therefore the priority to close the action. White 2 weeks Red 3 weeks Amber 5 weeks Green 12 weeks The easy Green NCRs regularly get closed first because they are easy. The severity rating bears no relationship on the required amount of time to close the NCR and therefore is not agreed by the actionee Auditors tend to agree that an action plan is put into place within the automatic deadline but record a verification date which becomes the actual completion date. Chasing Methods Slide 12 CQI Wessex Branch Top Management Support Top Management drive the importance of closing findings Top Management drive the importance of closing findings For example; a category 2 finding, the completion date set for 13 weeks at 6 weeks the action owner gets a weekly reminder at 10 weeks its escalated to the senior management Then chased by MD or GM on a weekly basis When the completion date is unreasonable it is amended New amended date is chased weekly to demonstrate this action will not disappear for nil returns the MD or GM sends an email asking for an update Slide 13 Top Management Support Closing NCRs and review action points should be part of normal business World class organisations rarely use the escalation process Completion of compliance targets should be built into annual appraisals Include an element of bonuses with closure of NCRs Appraisals based on shorter timescales would have better effect Are people fired for not completing their actions? Culture takes years to change CQI Wessex Branch Slide 14 Other Suggestions Remove ISO requirements and sell as best practice Remove ISO requirements and sell as best practice Show the action adds value Will save per annum Gives facts company 'x' was fined for not doing this correctly Slide 15 CQI Wessex Branch Writing the Action or NCR Write in plain English, avoid ISO speak Explain NCRs using simple examples to remove gobbledegook speak Remove ISO clause requirement Focus on the opportunity for business improvement reasons for raising NCR / action NCR / Action seen as positive rather than punitive CAR closure timescales defined Slide 16 ISO Speak! CQI Wessex Branch Risk is the combination of the probability of an event and its consequence Risk is the combination of the probability of an event and its consequence ISO 31000 defines risk as "effect of uncertainty on objectives ISO 31000 defines risk as "effect of uncertainty on objectives NOTE 1 An effect is a deviation from the expected positive and/or negative NOTE 1 An effect is a deviation from the expected positive and/or negative Slide 17 CQI Wessex Branch Ownership People won't respond to requests for action unless they believe they own the problem, obtain agreement from the REAL owner Without a clear owner, the buck will be passed and no one will pick it up Slide 18 CQI Wessex Branch Risk Carry out a risk assessment of the non-conformance Carry out an opportunity assessment of the improvement Use the risk rating to help prioritise action Make sure that they dont just see the number rather than understanding the effect of the risk / opportunity risk rating agreed at the audit closing meeting Slide 19 Risk Rating CQI Wessex Branch Slide 20 On Line NCRs With WRAG Rating Slide 21 CQI Wessex Branch KPIs percentage of NCRs closed out within the agreed period percentage of NCRs not closed out within agreed date By Risk ------------- By Owner } Slide 22 CQI Wessex Branch Due Dates vs. Risk Dont mix up the criticality of the NCR against close out date Dont mix up the criticality of the NCR against close out date The most critical NCR may have to take longer than a less critical one The most critical NCR may have to take longer than a less critical one Slide 23 Finally, The Gathered Wisdom is . CQI Wessex Branch Nag In Person Slide 24 Any Questions? CQI Wessex Branch