The purpose of this procedure is to ensure that corrective actions are used by senior management as a tool for improvement.


Preventive actions should be incorporated in to the quality system as a method of planning to prevent lost time, wastage and eliminate potential weaknesses at an early stage.  It may involve risk analysis of processes before non-conformances evolve.

This procedure refers to all operations which may eventually affect the quality of the Departments service.


REFERENCES: Procedure: Errors, customer complaints, corrective actions.



Risk Analysis
A long term examination of the processes and procedures operated by the EBME Department, with a view to identifying where weaknesses are likely to occur, and taking proactive action to eliminate them.

  • For example, if one particular department or ward is regularly reporting faults, but there is no fault found, a Risk Analysis should be carried out to determine the likely cause.


It is the responsibility of the department manager and the quality assurance manager to ensure that all aspects of this procedure are adhered to. This responsibility includes regular planned audits, and training of EBME staff to ensure they understand the quality processes.




Corrective Action
All documented non-conformances will be reviewed and the cause investigated.  These include data as the result of customer complaints, non-conformance reports, audit corrective action reports, management review meeting findings, process non-conformances and customer satisfaction feedback. Action will be taken which will be appropriate to the non-conformance and impact on the Department. Analysis of non conformances which is the responsibility of the quality assurance manager will be used as a tool to continually improve the Department's performance.
The quality assurance manager will evaluate corrective action in terms of eliminating aspects such as operating costs, costs of non-conformity, service performance, dependability of sub-contractors and the satisfaction of customers. The department manager and all staff should participate in the corrective action process.
The effectiveness and efficiency of the EBME department should be considered when actions are taken and the actions should be monitored to ensure that desired objectives are met.

In pursuing a corrective action, the quality assurance manager will identify sources of information, and collect information to define the necessary corrective actions which will be focused on eliminating causes of non-conformities in order to avoid recurrence.


  • For example, if a piece of equipment is found to have been on the goods in shelf for 6 months, and the repair turnaround time is 5 days, this is a non-conformance with the expected performance, and therefore a corrective action would be raised detailing how the EBME service would ensure devices are not left on the shelf for long periods of time.

Examples of sources of information for corrective action consideration include: customer complaints, non-conformity reports, internal audit reports, feedback from management review, data from satisfaction checklists, relevant quality management system records, feedback from departments, results of self-assessment.

Preventive Action
Preventive action, when documented will be reviewed by the quality assurance manager to eliminate the causes of non-conformances.  A monthly department meeting will be chaired by the dept manager who will form part of the preventive action risk analysis. Points for review may include reviewing customer needs and expectations, self assessment, manning levels, reviewing all processes, evaluating training, potential weaknesses, benchmarking, updating equipment and software and looking for early warnings of impending problems. The effectiveness of these actions will normally be reviewed at the following meeting.

All preventive action will be recorded and longer-term analysis of results will provide indications and data for continual improvement.  Changes to existing processes will take place when appropriate as the result of analysing preventive action or corrective actions. This may include documenting potential non-conformities and their causes, and evaluating the need for action to prevent occurrence of non-conformities, deciding on action needed, keeping records of results of action taken, and reviewing preventive action taken. The degree of corrective action and preventive action will depend on its projected impact on the department.

Continual improvement
To aid in ensuring the future of the EBME department and the satisfaction of our Trust customers, a culture has been created whereby the department manager, and the quality assurance manager involve customers/clients in actively seeking opportunities for improvement in the standard of workmanship and the associated service which they provide. To involve people, the department manager has created an environment so that all EBME personnel accept responsibility to identify opportunities for the department to improve its performance. To achieve this objectives have been set annually for key personnel, resources have been made available in terms of software, hardware and when appropriate manpower, weaknesses have been acted on, clients have been interviewed and the department performance measured and procedures, processes and working practices have been updated if appropriate.

Associated forms, processes, procedures
Corrective Action  Request Corrective Action  Request (CAR) status log Procedure  - Control of errors, customer complaints, corrective actions.




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