Continual Improvement Process
PURPOSE
The Office of the President recognises that the process of achieving quality is a continual process. The
purpose of this process is to outline the procedure used by all units within the Office of the President to
ensure continual improvement of our quality management system and the services we provide.
RESPONSIBILITY
Overall responsibility for this process lies with the Director of Quality; however, all units of the Office of the
President are responsible for continual improvement. The Quality Improvement Plan (QIP) is maintained by
the Quality Officer.
PROCEDURE
The Quality Improvement Plan is used by the Office of the President to record and monitor all quality-related
improvement suggestions. The QIP contains details of all quality-related improvement suggestions. The
following are used to identify the different sources of improvement suggestions:
COM
COR
GA
PI
POS
QA
QR
SA
SS
SUR
Complaint
Corrective Action
Gap Analysis
Process Improvement
Positive Customer Feedback
QMS Audit (Inter-Dept.)
Quality Review
Self-Audit
Staff Suggestion
Survey Feedback
The Action Plan is updated by the Quality Team to document newly identified activities and to update
progress on all activities recorded.
1. Continual improvement is a standing agenda item for all quality meetings.
2. New improvement suggestions are brought to the meeting by members of the quality team.
3. These are discussed by the team and agreement reached on: The activity; person responsible,
timeframe, source of action and the proposed action.
4. Once agreement is reached, the Quality Officer enters the details into Action Plan.
5. Actions are reviewed for progress at every meeting.
6. Once an identified improvement activity is complete, it is recorded in the ‘Completed Actions’
section of the QI Plan.
7. Actions that are currently outside the scope/remit of the Office of the President are recorded in the
‘On Hold’ tab.
8. When a decision is made not to pursue an action, the action item is recorded in the ‘Not Pursued’
tab with relevant justification.
9. Details of the review of QIP are recorded in the minutes of quality meetings.
10. Trend data is produced for the annual management review of the QMS.
Office of the President
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Continual Improvement Process
Continual Improvement Framework
Our continual improvement framework incorporates both co-ordinated, central Office-level processes that
span all three units and local-level initiatives tailored by the units to best suit their local needs. The Office’s
approach to continual improvement is based on four principles:
1. Personal Responsibility: Fostering among staff a culture that promotes personal responsibility for
quality improvement. Staff engagement is promoted through overt support and commitment from
senior management; clear communication channels with staff; closing the feedback loop and
highlighting the tangible benefits that arise from implementing the quality improvement plan (QIP).
2. Capturing Enhancement Proposals: Enhancement proposals are captured through various means,
including staff suggestions for improvement, customer feedback and focus groups, QMS audit
findings and capturing feedback from quality review activities. All enhancement proposals are
recorded in the QIP.
3. Implementing Enhancements: Regular review and monitoring of QIP is undertaken by the quality
team. Unit-specific actions are reviewed at unit level. Each activity has an assigned owner and
timeline. Completed actions are reviewed by the quality team and moved to a separate section of
the QIP.
4. Disseminating Good Practice: Trend data is analysed annually at the management review meeting.
Positive feedback is also captured. Expertise is shared across units through our QMS audit process
which ensures that QMS auditors do not audit their own procedures. Office staff members also act
as auditors for other UL support units. This allows for a cross-fertilisation of ideas and the
dissemination of best practice.
Figure 1: Continual improvement framework
Office of the President
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Continual Improvement Process
Internal Audit / Self-Assessment
The Internal Audit / Self-Assessment process ensures continual implementation, maintenance and
improvement of all elements of the quality management system and the services provided by Office of the
President. There is an annual audit schedule which is published and a team of trained QMS auditors who
conduct regular audits of all aspects of the QMS. Follow-up actions from internal audits are tracked by the
quality team and the overall audit findings are discussed at the annual management review of the QMS.
Quality Team
The Office of the President Quality Team comprises representatives from the various units of the Office.
Members of the Quality Team for the Office of the President are listed on the Web. The quality team meet at
least monthly to review the development and continual improvement of the quality management system.
Minutes of all quality meetings are recorded on SharePoint.
Review of Actions
The Quality Improvement Action Plan is reviewed by the quality team at each meeting. Trend data is
presented to the Management Team for review at the management QMS review meeting.
DOCUMENTATION


Office of the President Audit/Self-Assessment Process
Office of the President Quality Improvement Action Plan
RECORDS
Audit reports are kept for a period of 3 years.
Records on the Quality Improvement Action Plan are held for a period of 3 years.
The Office of the President is governed by UL’s Records Management and Retention Policy.
Minutes and meeting summaries are available as set out above.
PROCESS VERIFICATION
Evaluation of process effectiveness is carried out using internal and QMS audits. Changes to the process are
put in place as required and as appropriate.
REVISION HISTORY
Revision No.
1
Date
Nov ‘15
2
Dec ‘15
3
July ‘16
4
July ‘16
5
Nov ‘16
Office of the President
Approved by:
Director of
Quality
Director of
Quality
Director of
Quality
Director of
Quality
Director of
Quality
Details of Change
Initial Release
Process Owner
Quality Team
Minor changes required following
audit recommendations.
Updated to record how we deal
with actions not pursued and
actions on hold (new steps 7 and
8).
Included CI Framework devised
during the writing of the SAR.
Removed reference to individual
level plans. Updated CI process
diagram.
Quality Team
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Quality Team
Quality Team
Quality Team
Rev. 5