10. Improvement
10.1 General
Improvement is a deliberate activity. The organisation actively looks for opportunities and acts on them so the SHEQ management system delivers what it's supposed to.
Improvement work falls into three streams:
A
Improving products and services — both to meet current requirements and to anticipate where customer needs are heading
B
Correcting, preventing or reducing undesired effects
C
Lifting the performance and effectiveness of the management system itself
Types of Improvement
Correction
Immediate action to fix problems
Corrective Action
Eliminate root causes
Continual Improvement
Ongoing enhancement
Breakthrough Change
Significant improvements
Innovation
New methods and approaches
Re-organization
Structural changes
Improvement Opportunity Sources:
- Customer Feedback: Complaints, suggestions, and satisfaction surveys
- Internal Audits: Findings and observations from systematic reviews
- Performance Data: KPIs, metrics, and trend analysis
- Employee Suggestions: Frontline insights and improvement ideas
- Benchmarking: Comparison with industry best practices
- Management Review: Strategic direction and resource optimization
10.2 Incident, Nonconformity and Corrective Action
A defined process — covering reporting, investigation and action — runs whenever an incident or non-conformity occurs. It is maintained over time, not stood up ad hoc when something goes wrong.
Process Overview
React
Immediate response to incident/nonconformity
Evaluate
Assess need for corrective action
Review
Examine risk assessments
Implement
Execute corrective actions
Verify
Check effectiveness
Immediate Response
Control, correct, and address consequences
Investigation
Determine root causes and similar occurrences
Risk Review
Assess existing risk evaluations
Action Planning
Implement corrective actions using hierarchy of controls
Effectiveness Review
Verify action effectiveness and system updates
Key principle: Corrective action is sized to the actual or potential impact — minor issues do not get the full inquiry treatment, and serious ones do not get a quick patch.
Detailed 7-Step Process
When an incident or non-conformity hits, the response runs through seven steps:
1
React quickly — and, where it applies:
- Take action to bring the situation under control and correct it
- Deal with the immediate consequences
2
Evaluate the need for corrective action — with employees involved and other relevant parties brought in — so the underlying cause is eliminated and the issue doesn't reappear here or elsewhere:
- Investigate the incident or analyse the non-conformity
- Identify the cause(s)
- Check whether similar issues have already happened, exist now, or could happen
3
Review existing risk assessments — SHEQ risks and others — in light of what was learned
4
Decide on and implement the action needed — including corrective action — applying the hierarchy of controls and the management of change
5
Re-assess SHEQ risks tied to any new or changed hazards before the action goes live
6
Verify effectiveness — does the action actually do what it was meant to do?
7
Update the SHEQ management system if the lesson points to a system-level change
Investigation Best Practices:
- Timely Reporting: Encourage immediate incident reporting
- No Blame Culture: Focus on system failures, not individual blame
- Structured Methods: Use root cause analysis techniques (5 Whys, Fishbone, etc.)
- Evidence Collection: Gather physical evidence, witness statements, and data
- Team Approach: Include diverse perspectives in investigations
- Learning Focus: Treat incidents as learning opportunities
Why speed matters: The faster an incident gets reported and investigated, the faster the underlying hazard can be removed and its SHEQ risk taken down.
Documentation Requirements
Required documentation
Records are kept as evidence of:
1
What the incident or non-conformity was, and what was done about it
2
The results of any action — including how effective it turned out to be
Communication: These records reach the people who need them — relevant employees, employee representatives where they exist, and other interested parties.
Documentation Best Practices:
- Incident Reports: Detailed description of what happened, when, where, and who was involved
- Investigation Records: Evidence collected, analysis performed, and conclusions reached
- Root Cause Analysis: Methodology used and causes identified
- Action Plans: Specific actions, responsibilities, and timelines
- Effectiveness Reviews: Follow-up assessments and verification results
- Lessons Learned: Knowledge captured for organizational learning
- Trending Analysis: Patterns and recurring issues identification
Record Retention Guidelines
- Incident Records: Minimum 7 years or as required by regulation
- Investigation Files: Complete records including all evidence
- Corrective Actions: Implementation and effectiveness verification
- Communication Records: Evidence of stakeholder notification
- System Changes: Documentation of management system updates
10.3 Continual Improvement
The SHEQ management system gets better over time — its suitability, adequacy and effectiveness all move forward — through five practices:
1
Lifting SHEQ performance
2
Building a culture that backs the management system rather than works around it
3
Getting employees involved in implementing improvements
4
Communicating results back to employees and their representatives
5
Keeping records that evidence the improvement work
Continual Improvement Cycle
Plan
Identify opportunities and develop improvement plans
Do
Implement improvement actions and changes
Check
Monitor and measure results and effectiveness
Act
Standardize successful improvements
Continual Improvement Framework:
- Performance Enhancement: Systematic approach to improving SHEQ metrics and outcomes
- Cultural Development: Foster a culture of continuous learning and improvement
- Employee Engagement: Encourage and facilitate employee participation in improvement initiatives
- Communication Strategy: Share improvement results and successes across the organization
- Knowledge Management: Capture and retain organizational learning from improvement activities
Kaizen
Small, incremental improvements
Six Sigma
Data-driven process improvement
Lean
Waste elimination and efficiency
Innovation
Creative solutions and new approaches
Success Factors for Continual Improvement:
- Leadership Commitment: Visible support and resource allocation from top management
- Employee Empowerment: Give employees authority to implement improvements
- Data-Driven Decisions: Base improvements on factual information and analysis
- Process Focus: Concentrate on improving processes rather than blaming people
- Systematic Approach: Use structured methodologies and tools
- Recognition Programs: Acknowledge and reward improvement contributions
- Training and Development: Build improvement capabilities throughout the organization