capa-officer

CAPA Officer

Corrective and Preventive Action (CAPA) management within Quality Management Systems, focusing on systematic root cause analysis, action implementation, and effectiveness verification.

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Table of Contents

• CAPA Investigation Workflow
• Root Cause Analysis
• Corrective Action Planning
• Effectiveness Verification
• CAPA Metrics and Reporting
• Reference Documentation
• Tools

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CAPA Investigation Workflow

Conduct systematic CAPA investigation from initiation through closure:

1. Document trigger event with objective evidence
2. Assess significance and determine CAPA necessity
3. Form investigation team with relevant expertise
4. Collect data and evidence systematically
5. Select and apply appropriate RCA methodology
6. Identify root cause(s) with supporting evidence
7. Develop corrective and preventive actions
8. Validation: Root cause explains all symptoms; if eliminated, problem would not recur

CAPA Necessity Determination

Trigger Type	CAPA Required	Criteria
Customer complaint (safety)	Yes	Any complaint involving patient/user safety
Customer complaint (quality)	Evaluate	Based on severity and frequency
Internal audit finding (Major)	Yes	Systematic failure or absence of element
Internal audit finding (Minor)	Recommended	Isolated lapse or partial implementation
Nonconformance (recurring)	Yes	Same NC type occurring 3+ times
Nonconformance (isolated)	Evaluate	Based on severity and risk
External audit finding	Yes	All Major and Minor findings
Trend analysis	Evaluate	Based on trend significance

Investigation Team Composition

CAPA Severity	Required Team Members
Critical	CAPA Officer, Process Owner, QA Manager, Subject Matter Expert, Management Rep
Major	CAPA Officer, Process Owner, Subject Matter Expert
Minor	CAPA Officer, Process Owner

Evidence Collection Checklist

• Problem description with specific details (what, where, when, who, how much)
• Timeline of events leading to issue
• Relevant records and documentation
• Interview notes from involved personnel
• Photos or physical evidence (if applicable)
• Related complaints, NCs, or previous CAPAs
• Process parameters and specifications

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Root Cause Analysis

Select and apply appropriate RCA methodology based on problem characteristics.

RCA Method Selection Decision Tree

Is the issue safety-critical or involves system reliability?
├── Yes → Use FAULT TREE ANALYSIS
└── No → Is human error the suspected primary cause?
    ├── Yes → Use HUMAN FACTORS ANALYSIS
    └── No → How many potential contributing factors?
        ├── 1-2 factors (linear causation) → Use 5 WHY ANALYSIS
        ├── 3-6 factors (complex, systemic) → Use FISHBONE DIAGRAM
        └── Unknown/proactive assessment → Use FMEA

5 Why Analysis

Use when: Single-cause issues with linear causation, process deviations with clear failure point.

Template:

PROBLEM: [Clear, specific statement]

WHY 1: Why did [problem] occur?
BECAUSE: [First-level cause]
EVIDENCE: [Supporting data]

WHY 2: Why did [first-level cause] occur?
BECAUSE: [Second-level cause]
EVIDENCE: [Supporting data]

WHY 3: Why did [second-level cause] occur?
BECAUSE: [Third-level cause]
EVIDENCE: [Supporting data]

WHY 4: Why did [third-level cause] occur?
BECAUSE: [Fourth-level cause]
EVIDENCE: [Supporting data]

WHY 5: Why did [fourth-level cause] occur?
BECAUSE: [Root cause]
EVIDENCE: [Supporting data]

Example - Calibration Overdue:

PROBLEM: pH meter (EQ-042) found 2 months overdue for calibration

WHY 1: Why was calibration overdue?
BECAUSE: Equipment was not on calibration schedule
EVIDENCE: Calibration schedule reviewed, EQ-042 not listed

WHY 2: Why was it not on the schedule?
BECAUSE: Schedule not updated when equipment was purchased
EVIDENCE: Purchase date 2023-06-15, schedule dated 2023-01-01

WHY 3: Why was the schedule not updated?
BECAUSE: No process requires schedule update at equipment purchase
EVIDENCE: SOP-EQ-001 reviewed, no such requirement

WHY 4: Why is there no such requirement?
BECAUSE: Procedure written before equipment tracking was centralized
EVIDENCE: SOP last revised 2019, equipment system implemented 2021

WHY 5: Why has procedure not been updated?
BECAUSE: Periodic review did not assess compatibility with new systems
EVIDENCE: No review against new equipment system documented

ROOT CAUSE: Procedure review process does not assess compatibility
with organizational systems implemented after original procedure creation.

Fishbone Diagram Categories (6M)

Category	Focus Areas	Typical Causes
Man (People)	Training, competency, workload	Skill gaps, fatigue, communication
Machine (Equipment)	Calibration, maintenance, age	Wear, malfunction, inadequate capacity
Method (Process)	Procedures, work instructions	Unclear steps, missing controls
Material	Specifications, suppliers, storage	Out-of-spec, degradation, contamination
Measurement	Calibration, methods, interpretation	Instrument error, wrong method
Mother Nature	Temperature, humidity, cleanliness	Environmental excursions

See references/rca-methodologies.md for complete method details and templates.

Root Cause Validation

Before proceeding to action planning, validate root cause:

• Root cause can be verified with objective evidence
• If root cause is eliminated, problem would not recur
• Root cause is within organizational control
• Root cause explains all observed symptoms
• No other significant causes remain unaddressed

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Corrective Action Planning

Develop effective actions addressing identified root causes:

1. Define immediate containment actions
2. Develop corrective actions targeting root cause
3. Identify preventive actions for similar processes
4. Assign responsibilities and resources
5. Establish timeline with milestones
6. Define success criteria and verification method
7. Document in CAPA action plan
8. Validation: Actions directly address root cause; success criteria are measurable

Action Types

Type	Purpose	Timeline	Example
Containment	Stop immediate impact	24-72 hours	Quarantine affected product
Correction	Fix the specific occurrence	1-2 weeks	Rework or replace affected items
Corrective	Eliminate root cause	30-90 days	Revise procedure, add controls
Preventive	Prevent in other areas	60-120 days	Extend solution to similar processes

Action Plan Components

ACTION PLAN TEMPLATE

CAPA Number: [CAPA-XXXX]
Root Cause: [Identified root cause]

ACTION 1: [Specific action description]
- Type: [ ] Containment [ ] Correction [ ] Corrective [ ] Preventive
- Responsible: [Name, Title]
- Due Date: [YYYY-MM-DD]
- Resources: [Required resources]
- Success Criteria: [Measurable outcome]
- Verification Method: [How success will be verified]

ACTION 2: [Specific action description]
...

IMPLEMENTATION TIMELINE:
Week 1: [Milestone]
Week 2: [Milestone]
Week 4: [Milestone]
Week 8: [Milestone]

APPROVAL:
CAPA Owner: _____________ Date: _______
Process Owner: _____________ Date: _______
QA Manager: _____________ Date: _______

Action Effectiveness Indicators

Indicator	Target	Red Flag
Action scope	Addresses root cause completely	Treats only symptoms
Specificity	Measurable deliverables	Vague commitments
Timeline	Aggressive but achievable	No due dates or unrealistic
Resources	Identified and allocated	Not specified
Sustainability	Permanent solution	Temporary fix

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Effectiveness Verification

Verify corrective actions achieved intended results:

1. Allow adequate implementation period (minimum 30-90 days)
2. Collect post-implementation data
3. Compare to pre-implementation baseline
4. Evaluate against success criteria
5. Verify no recurrence during verification period
6. Document verification evidence
7. Determine CAPA effectiveness
8. Validation: All criteria met with objective evidence; no recurrence observed

Verification Timeline Guidelines

CAPA Severity	Wait Period	Verification Window
Critical	30 days	30-90 days post-implementation
Major	60 days	60-180 days post-implementation
Minor	90 days	90-365 days post-implementation

Verification Methods

Method	Use When	Evidence Required
Data trend analysis	Quantifiable issues	Pre/post comparison, trend charts
Process audit	Procedure compliance issues	Audit checklist, interview notes
Record review	Documentation issues	Sample records, compliance rate
Testing/inspection	Product quality issues	Test results, pass/fail data
Interview/observation	Training issues	Interview notes, observation records

Effectiveness Determination

Did recurrence occur during verification period?
├── Yes → CAPA INEFFECTIVE (re-investigate root cause)
└── No → Were all effectiveness criteria met?
    ├── Yes → CAPA EFFECTIVE (proceed to closure)
    └── No → Extent of gap?
        ├── Minor gap → Extend verification or accept with justification
        └── Significant gap → CAPA INEFFECTIVE (revise actions)

See references/effectiveness-verification-guide.md for detailed procedures.

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CAPA Metrics and Reporting

Monitor CAPA program performance through key indicators.

Key Performance Indicators

Metric	Target	Calculation
CAPA cycle time	<60 days average	(Close Date - Open Date) / Number of CAPAs
Overdue rate	<10%	Overdue CAPAs / Total Open CAPAs
First-time effectiveness	>90%	Effective on first verification / Total verified
Recurrence rate	<5%	Recurred issues / Total closed CAPAs
Investigation quality	100% root cause validated	Root causes validated / Total CAPAs

Aging Analysis Categories

Age Bucket	Status	Action Required
0-30 days	On track	Monitor progress
31-60 days	Monitor	Review for delays
61-90 days	Warning	Escalate to management
>90 days	Critical	Management intervention required

Management Review Inputs

Monthly CAPA status report includes:

• Open CAPA count by severity and status
• Overdue CAPA list with owners
• Cycle time trends
• Effectiveness rate trends
• Source analysis (complaints, audits, NCs)
• Recommendations for improvement

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Reference Documentation

Root Cause Analysis Methodologies

references/rca-methodologies.md contains:

• Method selection decision tree
• 5 Why analysis template and example
• Fishbone diagram categories and template
• Fault Tree Analysis for safety-critical issues
• Human Factors Analysis for people-related causes
• FMEA for proactive risk assessment
• Hybrid approach guidance

Effectiveness Verification Guide

references/effectiveness-verification-guide.md contains:

• Verification planning requirements
• Verification method selection
• Effectiveness criteria definition (SMART)
• Closure requirements by severity
• Ineffective CAPA process
• Documentation templates

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Tools

CAPA Tracker

# Generate CAPA status report
python scripts/capa_tracker.py --capas capas.json

# Interactive mode for manual entry
python scripts/capa_tracker.py --interactive

# JSON output for integration
python scripts/capa_tracker.py --capas capas.json --output json

# Generate sample data file
python scripts/capa_tracker.py --sample > sample_capas.json

Calculates and reports:

• Summary metrics (open, closed, overdue, cycle time, effectiveness)
• Status distribution
• Severity and source analysis
• Aging report by time bucket
• Overdue CAPA list
• Actionable recommendations

Sample CAPA Input

{
  "capas": [
    {
      "capa_number": "CAPA-2024-001",
      "title": "Calibration overdue for pH meter",
      "description": "pH meter EQ-042 found 2 months overdue",
      "source": "AUDIT",
      "severity": "MAJOR",
      "status": "VERIFICATION",
      "open_date": "2024-06-15",
      "target_date": "2024-08-15",
      "owner": "J. Smith",
      "root_cause": "Procedure review gap",
      "corrective_action": "Updated SOP-EQ-001"
    }
  ]
}

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Regulatory Requirements

ISO 13485:2016 Clause 8.5

Sub-clause	Requirement	Key Activities
8.5.2 Corrective Action	Eliminate cause of nonconformity	NC review, cause determination, action evaluation, implementation, effectiveness review
8.5.3 Preventive Action	Eliminate potential nonconformity	Trend analysis, cause determination, action evaluation, implementation, effectiveness review

FDA 21 CFR 820.100

Required CAPA elements:

• Procedures for implementing corrective and preventive action
• Analyzing quality data sources (complaints, NCs, audits, service records)
• Investigating cause of nonconformities
• Identifying actions needed to correct and prevent recurrence
• Verifying actions are effective and do not adversely affect device
• Submitting relevant information for management review

Common FDA 483 Observations

Observation	Root Cause Pattern
CAPA not initiated for recurring issue	Trend analysis not performed
Root cause analysis superficial	Inadequate investigation training
Effectiveness not verified	No verification procedure
Actions do not address root cause	Symptom treatment vs. cause elimination