University-wide procedure for internal and external environmental auditing

PROCEDURE
Policymaker: Sustainability Manager
Valid from: 29 March 2019
Amended as of: 24 February 2023
Registration number: V-2023-0004-10
Responsible for review and queries: KTH Sustainability Office

1. Purpose

The purpose of this procedure is to describe how internal and external environmental audits are planned, conducted, followed up, documented and communicated.

2. Scope/delimitation

The procedure covers all KTH activities.

3. Definitions

Internal environmental audit

A systematic, independent and documented review process aimed at evaluating the organisation’s environmental performance and determining whether the requirements in the environmental management standard (ISO 14001) and the Regulation on environmental management in government agencies (2009:907) are met. The audit is performed by internal environmental auditors on behalf of the President.

External environmental audit

A systematic, independent and documented process that aims to determine whether the requirements of the environmental management standard (ISO 14001) are met. An external audit decides whether the organisation is allowed to keep its environmental certificate. The audit is performed by a contracted independent certification body.

Non-conformance

A non-conformance is the failure to fulfil a requirement. The requirement may be formulated in the environmental management standard ISO 14001, the environmental management system, environmental legislation or other binding requirements.

Preventive measure

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

Corrective action

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

Suggestions for improvment

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

Audit plan

The general document describing how internal audits are planned at KTH over a three-year period.

Audit programme

The detailed programme established for each audit and describing the areas to be audited, the persons to be interviewed and the sites to be visited.

4. Responsibilities

• The President is the client for the internal and external environmental audits.

• The Sustainability Manager bears general responsibility for ensuring that internal and external environmental audits are conducted.

• The Sustainability Manager is responsible for providing KTH’s management with information on the planning, implementation and results of internal and external environmental audits.

• The Sustainability Manager is responsible for providing the management at the schools and OS with information on the planning, implementation and results of internal and external environmental audits.

• The sustainability strategist establishes an audit programme and schedules audits.

• The sustainability strategist liaises with the external certification body.

• Managers at the schools and OS are responsible for ensuring that the internal and external environmental audits are conducted as planned, and for taking the necessary action to address non-conformances and suggestions for improvement in their respective organisations.

• Internal environmental auditors are responsible for planning, conducting audits, reporting and following up on non-conformances and suggestions for improvement according to adopted procedures and templates. Required qualifications are defined in the job description. An audit manager bears general responsibility for the audit.

• Managers and fellow-workers are responsible for participating in internal and external environmental audits and dealing with any non-conformances and suggestions for improvement that need to be addressed.

5. Implementation

5.1 Internal environmental audit

Internal environmental audits are planned by the KTH Sustainability Office. Internal environmental audits are planned and conducted according to an established audit plan. This plan takes into account operational processes that have an impact on the environment, changes affecting the organisation and the results of previous audits. Random checks of legal requirements are performed during the audit; for other monitoring of legal compliance, see “University-wide procedure for binding requirements – legal and other requirements”. Internal environmental audits are conducted annually.

Before the audit

Prior to each audit, an audit programme is established containing information on the areas to be audited, the dates, times, sites and persons whom the auditors are to meet, as well as the identities of the internal environmental auditors. The auditors review operational processes of significance to the environment, changes affecting the organisation and the results of previous audits, such as reports, non-conformances and suggestions for improvement. Suggestions for focus areas for the internal environmental audit are developed, and the Head of Sustainability secures support for these with the President.

Implementation of the audit

The audit is conducted according to the established audit programme and covers the management, schools and OS. Interviews are held with key individuals and site visits are conducted during the audit, and spot checks are conducted within the organisation.

After the audit - Audit report

After completing the audit, the internal environmental auditors compile a draft audit report. The draft is sent to the parties reviewed for comments and corrections. Comments must be received within 5 working days of receiving the draft report. A final audit report containing any non-conformances and suggestions for improvement is then sent out by the Sustainability Manager to all parties concerned.

Communication and dissemination of the report is decided and managed by schools and OS. The KTH Sustainability Office ensures that reports from internal environmental audits are registered. The report is also published on the KTH intranet.

After the audit - Dealing with non-conformances and suggestions for improvement

The reporting of non-conformances and suggestions for improvement is documented in a form for non-conformances and suggestions for improvement. Every non-conformance and suggestion for improvement is given a serial number in the form. The auditors communicate the non-conformances and suggestions for improvement to the relevant functions, which come back with an action plan to address the non-conformance or suggestion for improvement. The internal environmental auditors approve the schedule and actions. When the measures are completed, this is noted in the form. Non-conformances and suggestions for improvement are closed by the Sustainability Manager.

Serious non-conformances requiring immediate action must be addressed immediately.

5.2 External environmental audit

External environmental audits are conducted by a contracted accredited certification body. Audits are conducted once a year, and more extensive re-certification is conducted every three years. KTH’s management, OS and all schools are visited at that time. The scope of the audit is decided by the certification body.

Before the audit

External environmental audits are planned and conducted according to an established audit plan. Prior to the audit, an audit programme is established containing information on the areas to be audited, dates, times and the identities of the external environmental auditor(s). The external auditors review the relevant operational processes, changes to the organisation and the results of previous audits, such as reports, non-conformances and suggestions for improvement.

Implementation of the audit

The audit is conducted according to the established audit programme. Interviews are held with key individuals and site visits are conducted on the day of the audit.

After the audit - Audit report

The auditors write an audit report after completing the audit. This report shows which requirements have been audited and observations, as well as non-conformances/suggestions for improvement. The report is submitted at the end of the last audit day and sent to the sustainability strategist.

The Sustainability Manager is responsible for distributing the audit report to all parties concerned and ensuring that action is taken. Information is sent to KTH’s management, heads at OS, heads at the schools, and to parties who participated in the audit who are affected by suggestions for improvement and non-conformances.

After the audit - Dealing with non-conformances

When the audit has been completed, KTH has 90 days in which to close all non-conformances. The sustainability strategist is responsible for reporting non-conformances to the certification body. Reporting takes place in a web-based portal. The sustainability strategist is responsible for informing KTH’s management, OS and schools about which non-conformances need to be addressed.

KTH’s management, OS and schools are responsible for addressing non-conformances and reporting these to the sustainability strategist at the KTH Sustainability Office. The form must be returned with planned actions and a schedule within 60 days of completion of the external audit. The non-conformances are indicated by means of serial numbers. The Sustainability Manager must approve the schedule and actions in the form. When the actions are completed, this is reported in the form. Non-conformances are closed by the certification body.

Serious non-conformances requiring immediate action must be addressed immediately.

Dealing with suggestions for improvement

The suggestions for improvement arising from the external audit are summarised for KTH’s management, OS and schools and entered in the form intended for non-conformances and suggestions for improvement, along with a serial number. KTH’s management, OS and schools are responsible for reporting suggestions for improvement and reporting these to the sustainability strategist at the KTH Sustainability Office according to an established schedule. Suggestions for improvement are followed up by the external certification body at the time of the next audit.

6. Documentation

• Audit plan for KTH
• Audit programme
• Reports from internal environmental audits
• Reports from external environmental audits
• Form for non-conformances and suggestions for improvement

7. Change log