1 - Identification - clearly define the problem
The initial step in the process is to clearly define the problem or potential problem.
This should include:
• The source of the information
The specific source of the information is documented. There are many possible sources: Service requests, Customer complaints, Internal quality audits, Staff observations, Trend data, QA inspections, Process monitoring, Risk analysis.
This information is important for the investigation and action plan, but also useful for effectiveness evaluation and communicating the resolution of the problem.
• A detailed explanation of the problem
A description of the problem is written that is concise - but complete.
The description must contain enough information so that the specific problem can be easily understood.
• Documentation of the available evidence that a problem exists.
List the specific information, documents, or data available that demonstrates that the problem does exist.
This information will be very important during the investigation into the problem.
2 - Evaluation - appraise the magnitude and impact
The situation must be evaluated to determine both the need for action and then, the level of action required.
An evaluation should include:
•Potential Impact of the problem
Determine and document specifically why the problem is a concern and what the impact to the company and/or customers may be.
Concerns may include costs, function, product quality, safety, reliability, and/or customer satisfaction.
•Risk to the company or its customers
Based on the result of the impact evaluation, the seriousness of the problem is assessed.
The level of risk that is associated with the problem will affect the actions that are taken and the priority assigned to the situation.
•Remedial Action that may be required
The potential impact and risk assessment may indicate a need for some immediate action to remedy the situation until a permanent solution can be implemented.
In some cases the remedial action may be adequate. If so, the CAPA can then be closed, after documenting the rationale for this decision and completing appropriate follow up.
3 - Investigation - make a plan to research the problem
A written procedure for doing an investigation into the problem is created.
This procedure should include:
• The objectives for the action
The objective is a statement of the desired outcome(s) of the corrective or preventive action.
The action will be complete when all aspects of the objective have been met and verified.
• An investigation strategy
A set of specific instructions for determining the contributing and root causes of the problem is written.
This procedure directs a comprehensive review of all circumstances related to the problem and must consider: equipment, materials, personnel, procedures, design, training, software, external factors.
•Assignment of responsibility and required resources
It is important to assign someone the responsibility for each aspect of the investigation.
Any additional resources (financial, equipment, etc) should be identified and documented.
4 - Analysis - perform a thorough assessment
The investigation procedure is used to conduct the investigation into the cause of the problem.
•Every possible cause is identified and appropriate data collected.
A list of all possible causes is created which then form the basis for collecting relevant information, test data, etc.
The necessary data and other information is collected that will be used to determine the primary cause of the problem.
•The results of the data collection are documented and organized.
Data may come from a variety of sources: testing results and/or a review of records, processes, service information, design controls, operations, and any other information that may lead to a determination of the fundamental cause of the problem.
The data collected is organized into a useable form.
The resulting documentation should address all of the possible causes previously determined. This information is used to determine the root cause of the problem. The effectiveness of the analysis will depend on the quality and thoroughness of the information available.
•Everything related to the problem must be identified, but the primary goal must be to find the root cause.
Use the data to complete a Root Cause Analysis
This involves finding the actual cause of the problem rather than simply dealing with the symptoms.
Finding the primary cause is essential for determining appropriate corrective and/or preventive actions.
5 - Action Plan - create a list of required tasks
Using the results from the analysis, the best method(s) for correcting the situation (or preventing a future occurrence) is determined.
All of the tasks required to correct the problem and prevent a recurrence are identified and incorporated into an action plan.
The plan includes changes that must be made and assigns responsibility for the tasks.
•Actions to be completed
List all activities and tasks that must be accomplished to correct the existing problem or eliminate a potential problem, and prevent a recurrence.
It is very important identify all actions necessary to address everything that contributed to or resulted from the situation.
Needed changes to documents, processes, procedures, or other system modifications should be described.
Enough detail must be included so it is clearly understood what must be done and what the outcome of the changes should be.
Employee training is an essential part of any change that is made and should be made part of the action plan.
To be effective, all modifications and changes made must be communicated to all persons, departments, suppliers, etc. that were or will be affected.
6 - Implementation - execute the action plan
The Action Plan that has been developed is executed and all identified tasks and activities completed.
The actions that were taken are summarized and all modifications to documents, processes, etc. are listed.
7 - Follow Up - verify and assess the effectiveness
One of the most fundamental steps in the CAPA process is completing an evaluation of the actions that were taken.
This evaluation must not only verify the successful completion of the identified tasks, but also assess the appropriateness and effectiveness of the actions taken.
Have all of the objectives been met? (Did the actions correct or prevent the problem with assurances that the same situation will not happen again?)
Have all recommended changes been completed and verified?
Has training and appropriate communications been implemented to assure that all relevant employees understand the situation and the changes that have been made?
Has an investigation demonstrated that that the actions taken have not had any additional adverse effect on the product or service?
Make sure that appropriate information has been recorded that provides proof that all actions have been completed successfully.
A validation of the action is done. This must document that:
o The root cause of the problem has been solved,
o Any resulting secondary situations have been corrected,
o Proper controls have been established to prevent a future occurrence,
o The actions taken had no other adverse effects.
o Adequate monitoring of the situation is in place.
When the Follow Up has been finished, the CAPA is complete.
It should be dated, and signed by appropriate, authorized personnel.