Clause 10.3 Continual Improvement (secrets explained)

Table of Contents

• What is Continual Improvement?
• What Is A Management System?
• A Tool For Improvement
• Analysis And Evaluation
• Management Review
• ISO 14001:2015
• ISO 45001:2018
• For auditors:
• Questions that I will answer in future articles:

When tutoring students on courses for the British Standards Institute, I would often pose the question; “Is it continual improvement or continuous improvement?” When I read that question now I feel quite embarrassed at being so pedantic to ask such a question in the first place. However, there is a difference. The ISO 9001:2015 is quite specific in that it does ask for ‘continual’ improvement and not ‘continuous’ improvement.

Continuous improvement implies that improvements are made on a constant basis, but in reality, this is rarely the case. If you have followed and successfully implemented all of the requirements of the standard up to this point, you would be hard-pressed not to have made improvements. Those improvements will have been made in small steps and will have occurred on a gradual basis. This is what ‘continual’ improvement refers to in reality; small improvements over the whole of your organisation that occur over a period of time.

What is Continual Improvement?

If you are true to your intentions at implementing ISO 9001:2015, and not just using it as a tick-box exercise then continual improvement will happen, slowly but surely. Continual improvement is the essence and practical result of the Plan, Do, Check, Act process. I believe that all requirements you complete in your implementation of ISO 9001:2015 have improvements built into them. There are some very obvious clauses that shout out improvement such as:

• 6.1.2 actions to address risks and opportunities
• 6.2 quality objectives and plans to achieve them
• 6.3 planning for change
• 9.2 internal audit
• 9.3 management review
• 10.2 non-conformity and corrective action
  
  

As I’ve already stated, any and all clauses of ISO 9001:2015 if implemented correctly contribute to continual improvement. Take clause 4.1 ‘context of the organisation’ for instance where, following my advice, you will have performed a PESTLE and SWOT analysis. This single clause alone will have enabled you to identify your internal strengths and weaknesses and your external threats and opportunities. Having completed this exercise you can now begin implementing plans to mitigate any threats and maximise any opportunities. If you consider the position you were in before completing this exercise compared to your position upon completion I think you would agree that improvements have been made.

What Is A Management System?

I’m not going to list examples for each and every clause requirement, but I could, and so could you if you analysed the benefits of implementing each clause. One of the early questions that I pose when delivering a 1-day introduction course to a standard is; “What is a management system?” There is no right, wrong or definitive answer to this question but here are some of the definitions from a quick Google search:

• A management system is designed to identify and manage risks through the use of policies and procedures.
• A management system is the way in which an organization manages the interrelated parts of its business in order to achieve its objectives.
• A management is a tool to improve productivity in business processes or projects.
• A management system is a set of policies, processes and procedures used by an organization to ensure that it can fulfil the tasks required to achieve its objectives.
• Management Systems are systematic frameworks designed to manage an organization’s policies, procedures and processes and promote continual improvement.
  
  

This list is by no means extensive and if you perform a search you’ll find a great many more definitions. Reading these examples, you will no doubt realise that they all essentially say the same thing. I rather like the last example that appears in the list only because it mentions the phrase ‘continual improvement’. That same question appeared in the lead auditors course exam, and if you had answered it by stating “A management system is a tool for improvement”, I would have awarded you the marks.

A Tool For Improvement

If you can fully appreciate and communicate to all interested parties that a management system is simply a tool that is designed to achieve continual improvement then I think you will have success in implementing and using it.

Clause 10.3 Continual improvement requires that:

• Your organisation shall continually improve the suitability, effectiveness and adequacy of the management system.
  
  

The main drivers behind achieving this requirement are leadership and commitment, roles, responsibilities and authorities, adequate resources, effective communications and training, internal auditing, management review and the corrective action process.

Unless you are doing something decidedly wrong, if you have implemented all of the clauses from 4.1 through 10.2 you should be making small, continual stepped improvements. The exception to this is if you are only using the management system as a tick-box exercise, or if you have purchased an ‘off-the-shelf’ management system. In either of these scenarios, a UKAS accredited 3^rd-party auditor will identify this very quickly and you will almost certainly fail to gain certification to the standard.

This clause also requires you to:

• Consider the results of analysis and evaluation.
  
  

Analysis And Evaluation

Clause 9.1 is where you are required to perform your analysis and evaluation of your organisation’s processes, procedures, tasks, objectives etc. and also the effectiveness of the management system implementation. This is a data collection and organising exercise often performed by middle management. Data is collected and organised into a meaningful form by using pie charts, bar charts and Venn diagrams etc. driven by excel pivot tables. For ISO 9001:2015 high on the list of important data should be customer service and customer feedback results.

For data collection and analysis to be effective it needs to be a regular exercise, function or activity. For data analysis to be effective, it has to be timely. By this I mean the data analysis should happen as quickly as possible after the data collection. Data can be very dynamic and susceptible to change at short notice and therefore any meaningful analysis must be performed quickly. It’s also advisable to implement a process to assess the validity and accuracy of the collected data.

Who collects the data and when is it analysed? Well, I can’t answer the ‘who’ part of this question as I’m sure that your organisation has processes in place and also roles, responsibilities and authorities assigned for this task. When asking “when is it analysed?” well, management review sounds like a good idea don’t you think?

Management Review

If you were to examine the list of required inputs to management review at clause 9.3.2 you would find that you are to discuss the performance and the effectiveness of the management system and the results of analysis and evaluation. If you understand the purpose of a management review as per the requirements of ISO 9001:2015 you would know that its purpose is one of continual improvements. It’s the ‘Act’ part of the Plan, Do, Check, Act process of continual improvement. The inputs to management review are all of the things that could potentially be improved. The output from management review is all of the plans, tasks and actions for how you are going to improve them.

I’m sure that I’m preaching information here that is obvious and something that you already know, but it’s a good idea to fully understand how this all fits into the world of management system requirements. There is a direct line of sight here from clause 4.1, clauses 6.1, 6.2 & 6.3, clause 8, clause 9.2, clause 9.3 and clause 10.2. Briefly, you’re are establishing your organisational context, planning for risk and opportunities, establishing objectives and a global policy, implementing those plans into your operations, checking and discussing those plans for effectiveness and making changes for improvement where necessary.

ISO 14001:2015

The requirements remain essentially the same.

ISO 45001:2018

The requirements for this clause are a little more extensive beginning with:

The organisation shall promote continual improvement by;

1. Enhance safety performance; a management system is a tool for continual improvement and if you have implemented all requirements effectively, you should have enhanced your approach to safety by default.
2. Promote a culture that supports the safety management system; this will be driven by top management leadership and commitment. Your organisation’s culture towards the safety management system must be led by inspirational leadership, effective communication, education and training.
3. Promoting the participation of workers and implementing actions for continual improvement; the participation of workers is not only a requirement of the standard but also a requirement of health and safety law (European). Ensure effective lines of communication and participation of workers and their representatives during management review meetings. Ensure effective hazard reporting processes are implemented that encourage workers to identify and report on hazards and incidents. Provide workers with a simple mechanism to suggest improvements to safety.
4. Communicate the relevant results of improvements to workers; as already stated, provide a simple but timely way of communicating safety improvements to workers. See chapter 7.4 Communication, for ideas about how to do this.
5. Maintain and retain documented information as evidence of continual improvement; oddly, neither ISO 9001:2015 of ISO 14001:2015 has a requirement for this. Records of the output from management review, changes to hazard identification and control, updates to risk assessments and safe systems of work etc. are all documents and records that you can provide as evidence.

For auditors:

• Check internal audit non-conformities have fed into the corrective actions process
• Check the input and output records of management review
• Check that actions raised at management review have been completed
• Check that completed actions have been entered into the management system
• Check if data collected from monitoring and measuring is being analysed and acted upon at management review
• Check if risks and opportunities are being discussed and acted upon at management review
• Check for links between continual improvement and the provision of resources (or lack of)
  
  

ISO 14001:2015

As for ISO 9001:2015

ISO 45001:2018

As for ISO 9001:2015 and also:

• Check how workers can contribute to continual improvement
• Check how the results of continual improvement are communicated to workers
• Establish how a culture for continual improvement is led by top management
  
  

Questions that I will answer in future articles:

• How do you create a management system?
• What are the objectives of a management system?
• What are the benefits of implementing a management system?
• What are the 7 quality management principles?
• What should a quality management system include?
• Will management systems work individually in an organization?