Continual Improvement Procedure

Quality Management System Procedure

NWI-QMS-21

1 Purpose

This procedure defines the processes used by Northern Waterworks Inc. (NWI) for
ensuring continual improvement of the Quality Management System through the
application of best management practices, corrective actions, and preventive actions.
This procedure describes how such methods of continual improvement are initiated,
assigned, documented, implemented and validated as being effective.

2 Responsibility

Compliance Coordinators
NWI Top Management
Operations Managers
Operators

3 Procedure

3.1 Continual improvement: Best management practices

3.1.1 Continual improvement shall be achieved by incorporating the review and

consideration of best management practices into the management review
process documented in NWI’s Management Review Procedure [NWI-QMS-
20]. The Compliance Coordinator shall ensure that best management
practices, particularly those identified within annual Ministry drinking-water
inspection reports as recommendations and best practice issues, are
reviewed and considered at least once every thirty-six months during the
management review process. Management review action items shall be
assigned by Top Management where deficiencies are identified through the
review and consideration of best management practices.

3.1.2 The Compliance Coordinator, as QMS Representative, may also review

and consider best management practices in between management reviews.
Where significant deficiencies are identified, the Compliance Coordinator
shall notify NWI Top Management to initiate the assignment of an action
item. For the purposes of the management review, any assigned action
items would be classified as “an action item issued between management
reviews”.

Revision Date: April 2, 2019

Revision Level: 2
Internal Reference: NWI-QMS-21
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 3.2 Continual improvement: Quality Management System Corrective Actions

3.2.1 The primary method for ensuring continual improvement through Quality
Management System Corrective Actions is described in NWI’s Internal
Audit Procedure [NWI-QMS-19], such that all nonconformities identified
during the annual internal audit shall be assigned corrective actions.
Corrective actions may also be initiated following the identification of
nonconformities through other processes, including management reviews
and infrastructure reviews. An employee may also initiate a corrective
action. This corrective action process is separate from the formal process
for addressing nonconformities identified during third-party audits.

3.2.2 A Corrective Action Report (CAR) is issued for each nonconformity

identified through internal audits, through other processes, or by
employees. The Compliance Coordinator is responsible for completing
Section 1 (Details of Nonconformity) of the CAR. If a nonconformity is
identified by an employee, the employee shall notify the Compliance
Coordinator in order to initiate the corrective action process.

3.2.3 The Compliance Coordinator shall determine the person or persons who
are best positioned to 1) investigate the cause of the identified
nonconformity and 2) undertake action to correct the nonconformity and
prevent it from re-occurring. After Section 1 is completed, the CAR shall be
forwarded to the identified person or persons and Section 2 (Investigation
and Corrective Actions) shall be completed. Section 2 requires the
responsible personnel to investigate, identify and document the cause of
the nonconformity. Section 2 of the CAR also requires responsible
personnel to document the actions that will be taken to correct the
nonconformity and to prevent it from re-occurring. After Section 2 of the
CAR is completed, it shall be forwarded to the Compliance Coordinator.

3.2.4 The Compliance Coordinator shall review the actions taken to correct the
nonconformity, verify that they are implemented and are effective in
correcting and preventing the re-occurrence of the non-conformity. If the
Compliance Coordinator considers the corrective actions to be adequate,
implemented and effective, Section 3 (Corrective Action Closure) of the
CAR shall be completed and the issue closed.

If the corrective actions are not considered to be adequate, implemented or

effective, an explanation shall be provided by the Compliance Coordinator
to responsible personnel. The processes for investigating the cause of the
nonconformity and undertaking corrective action shall start over again, and
the CAR may be returned to the responsible personnel for revision.

To maintain independence during the validation process, the Compliance

Coordinator shall not validate their own CARs; such CARs shall be
validated by a member of NWI Top Management.

Revision Date: April 2, 2019

Revision Level: 2
Internal Reference: NWI-QMS-21
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 3.2.5 The Compliance Coordinator shall track and follow up on all identified
corrective actions associated with nonconformities. Generally, corrective
actions must be completed within 90 days of identification.

3.2.6 Blank and completed Corrective Action Reports [NWI-QMS-21-1] are

controlled in accordance with NWI’s Document and Records Control
Procedure [NWI-QMS-5].

3.3 Continual improvement: Quality Management System Preventive Actions

3.3.1 The primary method for ensuring continual improvement through Quality
Management System Preventive Actions includes assigning preventive
actions to opportunities for improvement and potential nonconformities
identified during internal audit processes. Preventive actions may also be
initiated following the identification of potential nonconformities through
other processes, including management reviews and infrastructure reviews.
An employee may also initiate a preventive action.

3.3.2 A Preventive Action Report (PAR) is issued for each potential

nonconformity identified through internal audits, through other processes, or
by employees. The Compliance Coordinator is responsible for completing
Section 1 (Details of Potential Nonconformity) of the PAR. If a potential
nonconformity is identified by an employee, the employee shall notify the
Compliance Coordinator in order to initiate the preventive action process.

The Compliance Coordinator shall review the potential nonconformity in

order to determine if preventive actions are necessary. This review shall be
documented in Section 1 of the PAR. If preventive actions are not
necessary, the PAR is closed as per section 3.3.4 of this procedure.

3.3.3 If preventive actions are required, the Compliance Coordinator shall

determine the person or persons who are best positioned to undertake
action to prevent the nonconformity from occurring. The PAR shall then be
forwarded to the identified person or persons and Section 2 (Preventive
Actions) shall be completed. Section 2 of the PAR requires responsible
personnel to document the actions that will be taken to prevent the
nonconformity from occurring. After Section 2 of the PAR is completed, it
shall be forwarded to the Compliance Coordinator.

3.3.4 The Compliance Coordinator shall review the actions taken to prevent the
potential nonconformity, verify that they are implemented and are effective
in preventing the occurrence of the nonconformity. If the Compliance
Coordinator considers the preventive actions to be adequate, implemented
and effective, Section 3 (Preventive Action Closure) of the PAR shall be
completed and the issue closed.

Revision Date: April 2, 2019

Revision Level: 2
Internal Reference: NWI-QMS-21
Page: 3 of 4

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 If the preventive actions are not considered to be adequate, implemented or
effective, an explanation shall be provided by the Compliance Coordinator
to responsible personnel. The processes for undertaking preventive action
shall start over again, and the PAR may be returned to the responsible
personnel for revision.

To maintain independence during the validation process, the Compliance

Coordinator shall not validate their own PARs; such PARs shall be
validated by a member of NWI Top Management.

3.3.5 The Compliance Coordinator shall track and follow up on all identified
preventive actions associated with potential nonconformities. Generally,
preventive actions must be completed within 90 days of identification.

3.3.6 Blank and completed Preventive Action Reports [NWI-QMS-21-2] are

controlled in accordance with NWI’s Document and Records Control
Procedure [NWI-QMS-5].

3.4 Monitoring continual improvement

Trends associated with regulatory compliance, best management practices and

audit results are evaluated annually as a component of the management review.

4 Revision History

Date Rev. # Comments

30-Sep-2017 1 Initial publication as a corporate procedure.
2-Apr-2019 2 Revised the procedure for managing preventive actions.

Revision Date: April 2, 2019

Revision Level: 2
Internal Reference: NWI-QMS-21
Page: 4 of 4

This document is considered uncontrolled when printed.