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Audit Observations:Root causes of failure External factors • Cultural Behavioral Internal factors • Structural • Attitudinal • Competency Knowledge based

Audit Observations:Root causes of failure

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Audit Observations:Root causes of failure. Internal factors Structural Attitudinal Competency Knowledge based. External factors Cultural Behavioral. External factors. No discipline. No respect for the law. The way we behave outside. Significant lack of - Hygiene Safety - PowerPoint PPT Presentation

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Page 1: Audit Observations:Root causes of failure

Audit Observations:Root causes of failure

External factors• Cultural• Behavioral

Internal factors• Structural• Attitudinal• Competency• Knowledge based

Page 2: Audit Observations:Root causes of failure

External factors

No disciplin

eNo respect for the law

No idols or models for good

behavior in the society

Significant lack of -• Hygiene• Safety

• Civil behavior

The way we behave

outside

Page 3: Audit Observations:Root causes of failure

So …. The gap

What we do outside

What needs to be done INSIDE

IS FAR TOO DIFFERENT !

Page 4: Audit Observations:Root causes of failure

Internal factors

• Owner –- Hands on- Commercial interests- Very little respect for Quality

- DOESN’T WANT TO “INVEST” IN GMP

• CEO –- Looks after marketing & finances- With an eye only on production and new products- Very little respect for Quality

Structural

Page 5: Audit Observations:Root causes of failure

- Or at least the plant head is a Quality assurance person?

Quality is only audit-centric and not product-centric

Do you know a company where –

- Head of the company [CEO] is a Quality assurance person?

Page 6: Audit Observations:Root causes of failure

ORGANIZATIONAL CHART

SITE QA HEADFG BATCH RELEASE

Page 7: Audit Observations:Root causes of failure

Internal factors continued …

Attitudinal –

• In denial mode – when hit by audit, DON’T WANT TO LOOK WITHIN.

• Tendency to short-cuts, jugaadbaji• Not completing documentation on line and on same day• Preference only to the production, batch-making. • Everything else is kept pending or postponed - till last 7 days

before an important audit.• PM and calibration never done on time.GMP CAN WAIT !

Page 8: Audit Observations:Root causes of failure

Internal Factors continued …

Competency –

• Unavailability of competent manpower• Inadequate salaries for deserving candidates• Pennywise pound foolish (long term benefits of GMP &

quality)• Use of outside experts, consultants is done only after audit

failure or just close to important audit rather than preventive or strengthening basis.

Page 9: Audit Observations:Root causes of failure

Internal factors continued …

Knowledge – The lack of knowledge

- subject knowledge- Logic behind various processes- Technology

NO ONE WANTS TO QUESTION THE WHYS AND HOWS OF PROCESSS, GO IN DETAILS WHICH HAMPERES INVESTIGATION IF BATCH FAILS.

e.g. In sterile operations, knowledge of basic microbiology is essential.

e.g. Knowledge of basic tablet technology is important to understand the ‘why?’ behind the processes.

Page 10: Audit Observations:Root causes of failure

When knowledge is lacking…..

You start ….Avoiding Evading

Hiding Short cutting

IF WE KNOW THE WHY’S AND HOW’S OF THE PROCESS AND FAILURE…

IT IS EASY TO FACE THEM AND SOLVE THEM RATHER THAN AVOID OR HIDE THEM. !!

This is where the QA comes in.

Page 11: Audit Observations:Root causes of failure

Most problems in audit are because –

• They are hidden from QA. • Production has no confidence on QA.

• QA is seen as outsiders and no less evil than the auditors.

Page 12: Audit Observations:Root causes of failure

QA - Friend, Not a Foe !!

• QA acts as a barrier and production also looks upon them as Barrier …… And not a solution provider.

• Most QA people themselves do not know this fact.

• QA can give systemic solutions to all problems in the plant.. Except problems with recruitment, increment, promotion

and removal of a person.

QA is an enabler of production. Not a barrier.

Page 13: Audit Observations:Root causes of failure

But… Problems with QA

• They do not read manufacturing SOPs or PDR of a product.

• They do not go into details of science of drug manufacturing and microbiology

• They are not empowered sufficiently by the management

• They do not take up responsibility of partnering with manufacturing.

• They do not take regular rounds on shop-floor.

Page 14: Audit Observations:Root causes of failure

Tools of QA

Page 15: Audit Observations:Root causes of failure

Role of QA • Encourage production to report incidences, deviations• Encourage the culture of openness • Be bold and cooperative where needed.• Win trust/ confidence of the production

• Read and understand all production SOPs• Help in root cause analysis and CAPA implementation• Provide valuable inputs and solutions [Not be just a document signing machine – Be it SOPs, logbooks, CTDs etc]

• Help in making guide lines • Harmonization of policies on which operating persons can build their documents.

Page 16: Audit Observations:Root causes of failure

SOPs

SOPs not at work stations but in drawers

SOPs cut & pasted from previous plants

SOPs are not read

by the ‘doers’

Poor understanding of the science and logic – SOPs are not mere

laws and rules to fear them.

Common Root causes of failure

Page 17: Audit Observations:Root causes of failure

Common root causes of failure continued ….

• CSV expertise not available within the plant

• Delayed and then backdated documentation

• Poor understanding of the factors affecting the product quality and patient safety

• QA is not taken in confidence when such need arises.

Page 18: Audit Observations:Root causes of failure

Common root causes of failurecontinued ….

• Ignoring simple GMP/QA principles while filling batches, manufacturing tablets, capsules

• Top management always thinks that GMP and ETP are unnecessary and waste of money.

• Neglect of GMP does not rebound / boomerang everyday but when it does, it is fatal, (while tablets, capsules, ampoules, vials are quantifiable every day !)

Page 19: Audit Observations:Root causes of failure

Common root causes of failurecontinued ….

• MQR meeting are not held at all or not taken seriously by the plant head upwards.

• Self inspection/IPQA is weak, very junior persons in QA are asked to “Go and check Production”. No check list.

• OR – If strong, then points just keep piling up without CAPA or end action.

• So QA has to take up responsibility and get done all these things to prevent failures.