Case Study in CARs

1. Case Study in CARs Jennifer Shackelford, QA Coordinator Water Pollution Control Lab City of Portland Environmental Services DATE 2015

2. Why me? • Always go to meetings, then someone can’t volunteer you in absentia • >28 years in environmental labs, 23 in municipal wastewater • Currently WPCL QAQC Coordinator • Change of heart regarding CARs

3. Disclaimer! The views and procedures expressed here are not those of ORELAP, but of the City of Portland WPCL. Some things might be personal opinions, but they will be work-related. Nothing I say will guarantee a finding-free audit. I just hope it helps and maybe I’ll learn something too.

4. How did we start? • A few CARs per year • Maintenance issues tracked separately • Notes in data to indicate some problems • Emphasis on corrections, not always causes • Used for the intractable or unusual • Possible copper contamination in filters • DI system filter change/BOD blank failure • LCS failure when all usual forms of troubleshooting didn’t yield results

5. How did we start… • Some years, fewer than 10 • Some years, none at all This Photo by Unknown Author is licensed under CC BY-NC-ND

6. Accreditation on the horizon We got serious about ORELAP accreditation. So we copied the template.

7. Why? • Because we have to • TNI standard tells us to • Not for discipline • Negative reinforcement might backfire • Learn from our mistakes • Part of the human experience • Time = $$ • Would you rather spend time improving or making the same mistakes? • Continuous improvement • The never-ending journey

8. Corrective Action Report • Document the problem • Look for the cause • Determine possible corrections • Track the corrections taken and the outcome • Follow up until CAR closure

9. How? Document the problem -keep it simple, just the facts -“sample x was analyzed out of hold for y” Look for the cause -review data, supporting QAQC, receiving documents, SOPs, related audits - discuss with those involved, dig deeper to uncover beyond “#1 didn’t look at the backlog”

10. How? Determine possible corrections - everything and the kitchen sink - these are possibles, you don’t have to do them all, and not all are equally likely - maybe a suggestion can improve a related process

11. How Track the corrections - we date and initial when something is done - if notification or training is needed, the dates and personnel are included. Follow until closure - sometimes it feels like they never close

12. When? • Sometimes knowing when NOT to do something helps - if the SOP indicates corrective actions - documented maintenance that fixed a problem - requests for clarification of results - “expected random QC failures”

13. When for real… • Uncorrectable lab error that affects sample results • When random QC errors cease to be random • Audit findings/PT misses • Random non-conformances that don’t negate results

14. Who? • Most are initiated by the QAQC Coordinator • Details of what happened left up to those involved • Root cause may be group effort • Non-lab group involvement • List of corrective actions may also be group effort

15. Keeping track of it • Electronically, in a place everyone can access • A list of all CARs • Reminders to check the list periodically--Outlook • Follow-up meetings to keep corrective actions going • Staff meeting discussions noted

16. CARs are your friend They help you with your problems without judgement. They’re always there when you need them. Sometimes you have to like them whether they deserve it or not. This Photo by Unknown Author is licensed under CC BY-SA

17. Thanks for listening! • Jennifer Shackelford • Jennifer.Shackelford@portlandoregon.gov