Gaps and deficiencies identified during program reviews should be recorded and addressed through a corrective action program. Gaps or deficiencies in the program may be identified during training, drills, exercises, post-incident critiques, regulatory compliance audits, insurance surveys and from lessons learned.
Corrective Action Program
The corrective action program should document information on deficiencies. A table similar to the one on this page can be used. Include a full description of the deficiency; the action that should be taken; the resources required to address the deficiency; and justification for the need to correct the deficiency. Action on deficiencies should be assigned to the person or department best able to address the issue. A due date should be assigned and the corrective action database reviewed regularly to track progress. The status column should be updated until the deficiency has been addressed.
All program gaps or deficiencies are not equally important. Prioritization of corrective actions is helpful because funding and time are usually limited. Prioritization can also identify significant deficiencies that should be reported to management and corrected as quickly as possible. Criteria or categories for corrective action may include the following:
- Hazards to health and safety
- Regulatory compliance
- Hazards to property, operations, the environment or the entity (e.g., image or reputation)
- Conformity to national standards
- Following industry best practices
Significant deficiencies should be reported to management along with appropriate information to explain the problem, how to correct it and the reasons it needs to be addressed in order to gain management support for action. Management should also be periodically informed of the status of corrective actions until deficiencies have been resolved.