Performance evaluation collapse at a 40-site FM provider
Meridian Facilities Services delivers hard and soft FM to 40 client sites under a single certified FM system. Performance reporting rests on a monthly SLA dashboard. During a surveillance audit you find four things. First, all internal audits for the past 18 months were performed by the quality manager using a checklist he wrote himself, and covered only the head office. Second, management review minutes from the last three meetings record only debtor days, gross margin and staff turnover. Third, the corrective action log holds 63 open items, 22 of them older than 12 months, with no entry describing whether any action actually worked. Fourth, client satisfaction is measured only by counting complaints, and the complaint data is never analysed for trends. The operations director says monthly client meetings 'cover performance', but no minutes are retained. The quality manager adds that a new digital dashboard, built last week, will solve all of this.
1. Identify the failures against ISO 41001 and explain how you would grade them as minor or major.
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Four linked elements of clauses 9 and 10 are failing. Clause 9.1 requires determination of what to monitor and measure, the methods used, when monitoring occurs, and the analysis and evaluation of results. Counting complaints without trend analysis, and holding performance meetings without records, does not amount to analysis and evaluation. Clause 9.2 requires an internal audit programme planned with regard to the importance of processes, changes and previous results, and audits performed objectively and impartially; a programme confined to head office for 18 months, executed by the manager who owns the quality system, meets neither coverage nor objectivity. Clause 9.3 requires management review to consider defined inputs and produce decisions on improvement and resource needs; an agenda of debtor days and staff turnover does not. Clause 10.2 requires evaluation of the effectiveness of corrective action; 63 open items, 22 older than a year, with no effectiveness check, show the process runs without closing the loop.
On grading: a major nonconformity is normally one where a required element is absent, or where a systemic breakdown means the system cannot be relied on to achieve its intended outcomes; a minor is an isolated lapse that does not undermine the system. Here the organisation has no functioning mechanism to know whether its FM system works. I would expect 9.2 and 9.3 to be graded major, and 9.1 and 10.2 either major or consolidated into the same systemic finding. Before finalising I would check whether other evidence contradicts this picture, apply the certification body's grading criteria, and record the rationale - the grade is a judgement, not a formula.
2. Write the nonconformity statement for the internal audit issue in a form that would survive challenge at the closing meeting.
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A defensible nonconformity has three parts: the requirement, the objective evidence, and a statement of what was not done. It states facts, not opinions, and does not prescribe the solution.
Requirement: ISO 41001:2018, clause 9.2 - the organisation shall conduct internal audits at planned intervals, the audit programme shall be planned taking into consideration the importance of the processes, changes affecting the organisation and the results of previous audits, and auditors shall be objective and impartial.
Objective evidence: the internal audit schedule for the period January to December showed six audits, all scoped to head office processes; audit reports IA-01 to IA-06 were signed by the quality manager; no audit records existed for any of the 40 client sites or for site-level service delivery; interview with the quality manager confirmed he both maintains the FM system documentation and audits it.
Statement: 'The internal audit programme did not cover the delivery of FM services at client sites, and all audits in the period were performed by the manager responsible for the FM system being audited. The organisation has therefore not demonstrated that internal audits are planned across the scope of the FM system or conducted with objectivity and impartiality.'
Note what the statement avoids: naming individuals as incompetent, quoting hearsay, or saying the audit 'should have covered 40 sites'. The evidence says what was covered and by whom; the requirement supplies the criteria.
3. The quality manager presents the new dashboard, built last week, and asks that it be recorded as resolving the 9.1 finding. How do you treat it?
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I would not treat it as evidence of conformity for the audit period, and I would say so plainly and without hostility. Evidence must relate to the period audited. A tool created after the audit has begun cannot demonstrate that monitoring, analysis and evaluation operated over the previous twelve months. Accepting it would also reward building a dashboard at audit time rather than running a system.
That does not make it irrelevant. I would verify whether the dashboard is actually implemented - is it populated, who uses it, are there records of decisions taken from it, has anyone been trained, is the data quality controlled? Depending on what I find, it becomes either an action the organisation is taking (reported as such) or a lead for the next audit. I would also distinguish correction from corrective action: the dashboard may address the symptom (no analysis) but not the cause (no requirement for analysis, no review of data by management).
If the auditee presses, I would explain the distinction between 'we have started something' and 'the requirement is met and effective', and note in the report that the dashboard was introduced during the audit and its effectiveness has not yet been verified. The finding stands against the audit period; the next surveillance audit will test whether the new tool is used and produces decisions.