4.0 Checking And Corrective Action

Consideration has been given to information types such as: external assessments, internal assessments, benchmarking against other organizations, historical records and performance indicators.

Information is collected on an informal or random basis.

A formal system exists which includes:

• The identification and ongoing evaluation of information types;
• Established frequencies for the collection of information;
• The collection of both programmatic and functional information;
• Qualification requirements for those performing assessments; and
• Information covering relevant operations and services.

Collection of information from appropriate levels and functions of the organization;

The collection of information by appropriate functional units to self-evaluate performance;

A processes for documenting and archiving information which allows ease of access to pertinent information; and

Systems which allow for collection of concerns from students, employees and the community.

However, some regulatory compliance records are retained.

Compliance records are legible, identifiable and traceable to the operation, activity or compliance requirement.

Such records are stored and maintained in such a way that they are not readily retrievable and protected against damage, deterioration or loss.

Other EMS records may not be retained.

Such records are legible, identifiable and traceable to the operation, activity or compliance requirement.

Such records are stored and maintained in such a way that they are readily retrievable and protected against damage, deterioration or loss.

Records to be retained are identified and retention times are established and recorded.

The record management procedure and system is reviewed periodically to ensure its adequacy and effectiveness.

Compliance assessments are not performed by all functional units and not for all laws and regulations for which they are responsible.

Verification that physical monitoring of environmental impacts is performed as required by regulation or legal requirement.

• A requirement that compliance assessments are performed for relevant functional units and for applicable environmental laws and regulations for which they are responsible;
• Established frequencies for performing compliance assessments;
• Qualification requirements for those performing assessments;
• Information is collected only by administrative or programmatic units.

A requirement for self-assessment by applicable functional units in order to evaluate their own performance;

The collection of information which verifies that the compliance assessment requirements of functional units are being met; and

Information that is documented and archived to provide ease of access to all pertinent individuals.

Information is analyzed by individual organizational units, but results are not shared throughout the organization.

Written procedures for analyzing information;

Sharing results throughout the organization;

Data analysis at functional and programmatic levels;

Using subject matter experts to analyze data;

Evaluating performance indicators against performance objectives;

Assessing tracking and trending data to proactively identify areas of concern; and

QA/QC performed for physical monitoring.

Results being documented and reported to senior management;

Results which are compared to internal performance objectives and external benchmarks or organizations;

Evaluation of performance, quality and efficacy; and

Identification of direct and root causes.

Actions are developed by persons who generally will not be involved in their implementation.

• Written Action Plans;
• Actions which address both direct and root causes;
• Lessons Learned being developed and disseminated;
• Appropriate levels of management and subject matter experts involved in action plan development; and
• Those responsible for implementing actions being involved in their development.

• All appropriate personnel and levels of management are informed of necessary actions;
• Completion dates and responsibility for each corrective action are clearly defined and tracked; and
• Development of improvement actions which include preventive and corrective actions and work to support aspects identified which are effective and critical to the implementation, sustainability and efficacy of the EMS.

Effectiveness is not evaluated.

Improvement action effectiveness is evaluated.

Lessons learned are developed, as appropria, and disseminated throughout the organization

Preventative and corrective actions are incorporated into appropriate procedures.

The evaluation occurs on an irregular basis.

Evaluation of the checking and corrective action program includes appropriate levels of management, program personnel and subject matter experts.

The checking and corrective action program is written and fully documented.

Results are shared with management.

Required changes are implemented and evaluated for effectiveness.