University-wide procedure for dealing with non-conformances and suggestions for improvement

PROCEDURE
Policymaker: Sustainability Manager
Valid from: 29 March 2019
Amended as of: 24 February 2023
Registration number: V-2023-0004-12
Responsible for review and queries: KTH Sustainability Office

1. Purpose

The purpose of this procedure is to ensure that fellow-workers deal correctly and efficiently with non-conformances and suggestions for improvement within KTH’s environmental management system. Non-conformances must be identified, corrected, improved and prevented in order to go on improving KTH’s environmental management system and environmental performance.

2. Scope/delimitation

The procedure covers the handling of non-conformances and suggestions for improvement within KTH’s activities.

The procedure covers only non-conformances and suggestions for improvement within the environmental management system that are related to issues in respect of the external environment.

3. Definitions

Non-conformance

A non-conformance is the failure to fulfil a requirement. The requirement may be formulated in the environmental management standard, the environmental management system, environmental legislation or other binding requirements.

Corrective measure

A measure to eliminate the cause of an observed non-conformance and to prevent its recurrence.

Suggestions for improvement

A suggestion for improvement of the environmental management system or the organisation’s environmental performance.

Preventive measure

An action taken to eliminate the cause of a potential non-conformance.

4. Responsibilities

The President, Sustainability Manager, heads of school, University Director and line managers are responsible for dealing with non-conformances and suggestions for improvement according to this procedure within their areas of responsibility.

All fellow-workers are responsible for dealing with non-conformances and suggestions for improvement according to this procedure.

The Sustainability Manager is responsible for dealing with non-conformances received, suggestions for improvement and questions, as well as passing on anything that concerns the organisation. In connection with the management review, the Sustainability Manager reports on non-conformances received, suggestions for improvement that need to be addressed by the management, and non-conformances and suggestions for improvement from the internal and external environmental audit.

5. Implementation

Non-conformances must be identified, corrected and prevented at different levels within OS and at the schools. Non-conformances must be documented and followed up in order to continuously improve and develop environmental work. Non-conformances may arise from failure to follow general procedures for the environmental management system, such as failure to establish action programmes, or when there is failure to follow local procedures at the schools, such as chemical product management procedures.

Non-conformances can be reported at both local and general level and must be constantly encouraged. Documentation is important in order to identify recurring problems and find the real reasons for the non-conformance. Suggestions for improvement in respect of environmental management are dealt with according to the same procedure as for non-conformances.

5.1 Non-conformance management

Reporting

• Non-conformances, suggestions for improvement and questions are mainly reported by means of forms on the KTH intranet.

• Non-conformances and suggestions for improvement sent via forms are automatically entered in Log non-conformances/suggestions for improvement in KTH’s environmental management system: an email notification is sent to kth-miljo@kth.se  when a non-conformance has been submitted using the form.

• Non-conformances reported in other ways, e.g. by email, are documented in the non-conformance log by the KTH Sustainability Office.

Handling

• Non-conformances and suggestions for improvement relating to a school or operational support (OS) are forwarded to the relevant responsible functions for handling. Responsible functions report back when a non-conformance is closed to the KTH Sustainability Office.

• Non-conformances and suggestions for improvement are dealt with by the KTH Sustainability Office. Questions must be answered as soon as possible, but within 10 working days at the latest.

• Non-conformances and suggestions for improvement where the cause has been identified and resolved are closed by the responsible manager. Closed non-conformances are noted as resolved in the template for non-conformance management and suggestions for improvement. Non-conformances and suggestions for improvement from the internal environmental audit are closed by the Sustainability Manager.

• The effect of non-conformances and suggestions for improvement is monitored on an ongoing basis and in connection with the internal and external audits.

• Non-conformances and suggestions for improvement form the basis for management review.

5.2 Non-conformance management at local level

• Non-conformances, suggestions for improvement and questions must also be dealt with locally at each school/OS.

• Non-conformances form the basis for management review.

5.3 What is a non-conformance, and when must they be reported?

A non-conformance is when a binding requirement is not fulfilled. These may be legal requirements, requirements in the environmental management standard or requirements that we ourselves have defined at KTH, such as policies, sustainability goals/climate goals or other steering documents.

Non-conformances relating to the environment and working environment overlap in many cases, especially with regard to laboratory activities. The main impact of a non-conformance determines the responsible function to which the non-conformance has to be reported.

Examples of non-conformances to be reported:

• Chemicals are not surrounded by embankments to prevent leakage.
• There are unlabelled chemicals in a laboratory.
• Sorting of waste does not work.
• Procedures, rules or legal requirements are not followed.
• The occurrence of a fire, incident or accident that has or may have an impact on the environment

6. Documentation

Log non-conformances/suggestions for improvement in KTH’s environmental management system. Documented non-conformances according to local procedures. Annual summary of non-conformances, suggestions for improvement and questions received.

7. Change log