ITD CORRECTIVE ACTION PROCEDURE
PURPOSE
As a general rule in ITD, corrective action is taken in response to individual issues, whereas
preventive actions are initiated in response to observed trends. This procedure outlines the process
for handling these actions. Complaints about any aspect of our service are logged via the web-based
call-log form, preceded with the word ‘Complaint’. Instructions for logging a complaint are outlined
on the web:
http://www2.ul.ie/web/WWW/Services/Information_Technology_Division/Contact_ITD. Complaints
are assigned to the relevant Section Head / Manager, or the Director of the Division. Individual calls
returned by customers who are not satisfied with the outcome are referred to the Division
Administrator, who will take appropriate action to ensure the issue is resolved to the satisfaction of
the customer.
PROCEDURE
All corrective actions are logged in RMS and are referred to as Improvement Action Items.
Categories for these are maintained in RMS. Details of the use of RMS are available in the RMS
working guidelines:
(http://www2.ul.ie/web/WWW/Services/Information_Technology_Division/Quality_Management_S
ystem/Working_Guidelines/General).
Using the RMS system provides the structure in ITD for reviewing problems and problem calls (nonconformities), determining their causes, evaluating, determining and implementing required action,
maintaining records and reviewing the effectiveness of the action taken.
All improvement action items are initiated by logging them in RMS, using call type ‘IAI’ and relevant
application code from the following applications:
EAF
NCF
PPR
QIM
QRG
SUP
External Audit Findings
Negative Customer Feedback
Process / Procedure Review
Quality Implementation Meeting
Quality Review Group Finding
Supplier
IAF
POS
PTA
QMR
SF
WSH
Internal Audit Findings
Positive Customer Feedback
Preventive Action / Trend Analysis
Quarterly Management Review
Survey Finding
Wish List!
The status code for logging an improvement action item is ‘57’.
The electronic version of this document is the latest version. It is the responsibility of the individual to ensure that any
paper material is the current version. Printed material is uncontrolled documentation.
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The following SLA and Priority levels have been set for improvement action item calls:
SLA
Priority
Time Frame
IAI1
5
1 month
IAI2
6
3 months
IAI3
7
1 year
Once details and source of the Improvement Action Item are listed, the item is assigned to the most
appropriate person in ITD using both the ‘customer’ and ‘member’ fields. The assigned person is
then responsible for reviewing the issue and determining the appropriate action to resolve the issue.
All progress against the action is recorded using the Notes field in RMS. When the action is
complete, it can be moved to code 58. This indicates that the action has been complete and is ready
for a review of its effectiveness. The relevant Section Head / Manager arranges for this review to
take place.
Once the review is complete and the action deemed to be effective, notes should be added to the
call in RMS, giving a summary of what was reviewed. The call can be moved to Code 99. If the
review finds that the action taken is not effective, the call will be returned to Code 57, outlining the
reason in the notes field.
For the monthly management quality meeting, a summary report showing the opened/closed status
of IAIs is discussed.
PROBLEM MANAGEMENT CALLS
If a trend emerges that a number of incidents are logged for a similar issue / problem, individual
incidents (calls) should be closed down in RMS, giving a work-around where possible, and the issue /
problem should then be logged as a ‘Problem Management’ call, by a member of ITD staff. Status
code 96 in RMS is reserved for Problem Management Calls.
Once a PM call is logged at code 96, an email is automatically sent to the Section Head / Manager,
outlining details of the problem. The number of new PM calls logged each week is recorded in the
weekly summary report. These are discussed at the weekly management meeting. All PM calls are
reviewed weekly at the management meeting and recorded in the minutes until the problem has
been satisfactorily resolved. Resolved PM calls are closed with Code 99.
Where a problem is deemed to be outside the control of ITD and waiting for external resolution (e.g.
new application version) the status code will be changed to 88. All calls at 88 will be reviewed at the
monthly quality meeting until resolved.
The electronic version of this document is the latest version. It is the responsibility of the individual to ensure that any
paper material is the current version. Printed material is uncontrolled documentation.
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RECORDS
Records are maintained in RMS for a minimum of 3 years after effectiveness closure.
PROCESS VERIFICATION
Evaluation of process effectiveness is carried out using Internal / External Quality Audits and the
Corrective Action process where the procedure itself is found to be the source of the problem under
investigation.
A review of Key Process Indicators (KPIs) is conducted at the Quarterly Management Review
meeting. Process performance is evaluated by reviewing the number of complaints at the monthly
quality meeting and reviewing the number of IAIs closed on target.
Problem management calls are reviewed weekly at the management meeting with details outlined
in the minutes.
Revision No.
Date
Approved by:
Details of Change
1
25/1/05
Mgt Team
Initial Release
2
13/4/05
Mgt Team
Updated procedure to include a better
effectiveness review process than just
management meeting review.
3
2 Jun ‘05
Kim O’Mahony
Revised title for consistency and
reformatted header info. Updated record
section to reflect correct retention time.
4
14 Nov 05
Kim O’Mahony
Updated list of IAI call codes to reflect list
in RMS. Recommendation from Internal
Audit (10 Nov ’05)
5
18 Oct ‘06
Kim O’Mahony
Revised call codes structure to reflect new
codes in V6 of RMS. The fix codes are now
used for categorisation of the IAIs.
6
18 Oct ‘06
Kim O’Mahony
Included details of prioritisation process for
IAI calls.
7
29 May ‘08
Kim O’Mahony
Included web link to RMS documentation,
updated Quality Officer title and included
two additional fix types for IAIs.
The electronic version of this document is the latest version. It is the responsibility of the individual to ensure that any
paper material is the current version. Printed material is uncontrolled documentation.
Page 3 of 5
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8
1 Sept ‘08
Kim O’Mahony
Included reference to the process of
handling returned RMS calls after closure.
9
22 Sept ‘08
Kim O’Mahony
Updated Process verification section to
include details of Key Process Indicator.
10
6 Apr ‘09
Kim O’Mahony
Changed reference to RMS code for IAI
from 97 to 57 for open action items and
from 98 to 58 for effectiveness review. This
is in order to allow us to correctly measure
the performance of IAI calls against t
targets.
11
28 Apr ‘09
Kim O’Mahony
Changed call type to IAI and applications to
the corresponding category listed on page
1 (following change control request
TD210021).
12
27 May ‘09
Kim O’Mahony
Updated link to RMS working guideline
following recent change in web addresses
in Arconics
13
14 Dec ‘09
Kim O’Mahony
Included new section on Page 2 to outline
the process for handling Problem
Management Calls and who is responsible
for logging them (Internal audit finding).
14
26 Jan ‘11
Kim O’Mahony
Included web-link in procedure to the ITD
Complaints procedure
15
2 Oct ‘12
Kim O’Mahony
Replaced ‘Quality Officer’ with ‘Section
Head / Manager’ and Division
Administrator to receive ‘returned calls’.
16
16 Jan ‘13
George Hayes
PM calls are discussed at the weekly
change control meeting instead of
operational management meeting –
findings of internal audit Dec ‘12
17
1 Jun '13
Brendan Lynch
PM calls which require external
intervention/changes are monitored
monthly
18
27 Dec ‘13
George Hayes
Add ‘Application’ code … RMS reference
XL270001
PM calls are reviewed by the weekly
management meeting – RMS reference
XL270002
The electronic version of this document is the latest version. It is the responsibility of the individual to ensure that any
paper material is the current version. Printed material is uncontrolled documentation.
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PM calls are closed with Code 99 – RMS
reference XL270003
19
22 Dec ‘16
Brendan Lynch
Changed wording around complaints and
removed reference to trend analysis – RMS
reference ZZAB3848
20
May 2017
Edel Gissane
Renamed to ‘Corrective Action procedure’
to align with ISO 9001:2015 standard
The electronic version of this document is the latest version. It is the responsibility of the individual to ensure that any
paper material is the current version. Printed material is uncontrolled documentation.
Page 5 of 5
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