Quality Risk Management as a Management Tool: Carl Johnson
Transcription
Quality Risk Management as a Management Tool: Carl Johnson
Quality Risk Management as a Management Tool: How to Create and Use a QRM Plan Carl Johnson ASQ Senior Member Certified Six Sigma Black Belt May 2007 Overview of Presentation Objectives Quality Risk Management (QRM) Context Background, Scope, Definition QRM Process and Methodology Case Example Matrices, Templates, Diagrams Wrap Up 1 Objectives Define and explain QRM in practical terms Show how it benefited one company Explain how you can use it as a business tool to get management focused on the right things and therefore to do the right things Show why risk-based planning is gaining credence in industry (especially pharmaceutical Good Manufacturing Practices) Give you a framework that can help you think about problems in a new/different way, and be more effective in your job 2 Overview of Presentation Objectives Quality Risk Management (QRM) Context Background, Scope, Definition QRM Process and Methodology Case Example Matrices, Templates, Diagrams Wrap Up 3 Background Risk management is as old as civilization Shipments split among several vessels Crops planted in separated fields Purpose is to reduce impact of loss Lessen frequency Lessen magnitude Risk is defined as the combination of Probability of harm Severity of harm Similar analysis is used in Failure Mode and Effects Analysis and other techniques 4 Scope People Product users Patients Employees Product Product quality Specifications Processes Scrap Rework 5 Definition QRM is the discipline of systematically evaluating the probability and severity of events that could happen throughout the value chain, and then creating plans to reduce the frequency and/or lessen the severity of those events. Source: Charter Consulting 6 Overview of Presentation Objectives Quality Risk Management (QRM) Context Background, Scope, Definition QRM Process and Methodology Case Example Matrices, Templates, Diagrams Wrap Up 7 Process Initiate Risk Management Process Risk Assessment Risk Identification Risk Management Tools Risk Analysis Risk Evaluation Risk Control Risk Reduction Risk Acceptance Risk Communication Risk Communication Risk Review acceptable Output/Result of the Risk Management Process Risk Acceptance Review Events Source: ICH 8 Risk Assessment Risk identification “What might go wrong?” Identification can be based on experience, judgment, design knowledge or any number of inputs. Risk analysis “What is the probability the identified risk will occur?” “What’s the severity if it does?” “How detectable will it be?” Ideally, the answers to these questions would be quantified, but at least they can be given a relative ranking suitable for later analysis. 9 Risk Assessment (cont) Risk evaluation Decide, based on the quantitative or relative rankings, which of the risks warrant further action in terms of the QRM plan. Output The output of the Risk Assessment phase is a prioritized list of risks for further review. 10 Risk Control, Communication, and Review Control Risk reduction is concerned with finding ways to avoid the risk (reduce its likelihood) or mitigate the risk (reduce its severity). Risk acceptance is a decision to accept the risk. This decision should be made on a case-by-case basis in line with the comments regarding economic considerations mentioned above. Hint: It is important in doing QRM planning to keep reasonably detailed notes about decisions that are made. 11 Risk Control, Communication, and Review Communication Don’t assume everyone knows or understands the issues Have a communication plan Review Learn from the planning experience and institutionalize it 12 Methodology Establish goals, objectives, and planning scope Structure the team and ensure organizational support Review available process documentation and outside information Create Process Flow Diagrams (PFDs) Identify risks Analyze and evaluate risks Develop recommendations Institutionalize the QRM process 13 Institutionalizing 14 Overview of Presentation Objectives Quality Risk Management (QRM) Context Background, Scope, Definition QRM Process and Methodology Case Example Matrices, Templates, Diagrams Wrap Up 15 Role Matrix REQUIREMENT AREA Charter QA Ops Sales Product Type and Distribution S P Intended Use and Customers S P Develop Flow Diagram Verify Flow Diagram P S F P F=Facilitate P=Primary S=Shared Operations includes Receiving, Warehousing, Manufacturing, Packaging, Shipping, Distribution 16 Representative Frequency and Severity Categories Risk Frequency Categories Category High Medium Low Negligible Description Frequency more than once per week Frequency of several times per month Frequency several times per year Frequency less than once per year Score 4 3 2 1 Risk Severity Categories Category High Medium Low Negligible Description Requires 200% inspection, requires re-inspection of sealed cartons, causes one or more batches to be rejected or aborted Requires rework to part of a batch Requires minor adjustment to manufacturing equipment or process No major action required Score 4 3 2 1 Note: Detectablity was not considered in this first-cut analysis as assumed critical risks were considered equally detectable. 17 Scoring Matrix Showing Risk Priority Numbers High risk area Risk Severity 4 3 2 1 4 8 12 16 3 6 9 12 2 4 6 8 1 2 3 4 1 2 3 Risk Frequency 18 4 Alternative Approach to RPN Definition RISK PRIORITY NUMBER MATRIX Frequency RPN Severity Severe Major Minor Negligible Frequent 25 20 10 8 Probable 18 15 10 5 Occasional 12 9 7 3 Remote 8 7 3 1 19 Process Flow Diagram MANUFACTURING PROCESS FLOW DIAGRAM (PFD) Raw Material Storage Room Raw Material Supply Start Receive incoming raw materials from supplier Complete receiving report, either manually or in BPCS and label Transport raw material to storage area/warehouse for quarantine Storage of raw materials in controlled atmosphere Inspection of raw materials by QA Warehouse Raw materials approved? Check receiving report Send samples to lab for QC testing: in/out of spec Complete inspection records NO Reject raw materials and label accordingly Complete incident/ non conformance report Storage of rejected raw materials in separate location End YES Release and label approved raw materials Transport to released work storage area for stock Materials responsibility ends Production Compounding responsibility begins Created by: Document Number: Weigh, verify, and secure raw material batch Date: Validated by: Go to Page 3 Date: Revision: Page: 1 of 8 20 Risk Analysis Template 21 Completed Risk Analysis Template 22 Risks Plotted Into PFD 23 Risk Severity Summary Level RPN Analysis High 7,8,9,20, 22,28,30,41, 45,50,51,55, 57,58,59,60 1,10,12,13, 14,21, 27,31,33,40, 47,49,52,54, 56, 49 6, 23, 25,32,35,36, 39,53 5,19,24,26 Medium 16,37,46 38 11 29,48 Low 18 3,17,34 2,15 Negligible 4 Low Medium Negligible High Risk Frequency Note: Risks in bold have been identified by management as requiring additional action 24 Recommended Actions Item # Risk Description Risk Score (Max = 16) 5 Creation of quarantine labels in raw materials receiving area 16 6 Incoming components may be out of spec. 12 11 pH adjustment of bulk solution. 9 19 Refrigerator temperature deviations. 16 23 Plunger insertion deviations (formerly “plungers sticking together”) 12 25 Variations in cartridge fill volume. 12 48 Bulk solution temperature falls below allowable limit. 12 53 PM in bags of washed plungers. 12 25 Summary Action Plan # 53 Risk Score 12 Identified Risk Particulate matter in bags of washed plungers Risk Description Particulate matter (PM) has been found in bags of washed plungers Recommendation Establish a supplier cleaning program with vendor including review of the vendors proposed cleaning processes and site inspections to verify agreed-upon operations. Define the agreed upon PM/cleanliness criteria and incorporate the criteria into the IQA procedures. Establish preventive maintenance procedures on plunger handling equipment and validate that no additional particulate matter is introduced. Assign a Project Manager to complete this task under the direction of the individuals listed below. Action Plan Person Responsible Due Date 9/1/05 for detailed plan which will include completion dates Monitoring Plan Who? Quality Assurance, Operations What? Monitor plunger PM How? Check PM criteria during IQA – QA Observe operations to ensure no PM is introduced - Operations How often? Per IQA procedures Critical Limits Critical limit is no lot of incoming plunger contains PM and no PM is observed within operations Validation Validation of the new practices will result from final inspection finding no PM inside cartridges Required Reporting QA will report to the Material Review Board (MRB) on a monthly basis regarding PM findings 26 Key Points A structured approach is important – PFDs, interviews, workshops, reporting Involving internal customers in workshops will improve the analysis (e.g. Receiving is a customer of Purchasing) Risk analysis benefits when research, experience and brainstorming interplay Management pays attention to good analysis and problem solving 27 Conclusion QRM is common sense QRM brings structure to risk analysis QRM gives direction to quality programs QRM should be tried, because . . . 28 Contact Information Carl Johnson Chicago, IL USA +1 312 399 9455 CarlLJohnson@Ameritech.net 29