Saturday, June 26, 2010

Writing a Procedure Doesn't Make it Happen

A firm correctly interpreted that the FDA had lost patience with their inability to sustain compliance as evidenced by repeated FDA 483 observations and the inevitable Warning Letter that arrived by certified mail to the corner office.

Rewind. What happened?

The firm had written an eloquent response to the observations that hit all the right notes. Improvements were evidenced by a revised procedure that was attached to the response, which satisfied the FDA for the moment—though the FDA noted they would see for themselves upon re-inspection.

And see for themselves they did—or rather, they didn’t.

The General Manager was stunned to hear the inspector declare at the close out meeting that there was no substantial improvement since the previous inspection.

“How can this be?” The GM’s question reverberated through the building as everyone ducked for cover and the search for the guilty began.

Unfortunately, this is a common problem, and it’s based on the unfounded notion that if you write a procedure, you make it so.

So, I’m here to declare that writing a procedure doesn’t make diddly happen.

In this instance, the theme of the FDA feedback was the ubiquitous “failure to thoroughly review the failure of a batch or any of its components to meet any of it specifications whether or not the batch has already been distributed.” But the specific issue doesn’t really matter. It could have been anything—the underlying problem remains the same.

It boils down to two things: organization capability and governance.

In this case, reasonable commitments were made to the FDA and appropriate changes were made to their deviation management procedure. However, the firm still lacked the resources and technical bench strength to conduct a thorough investigation and inadequate process knowledge to execute an effective corrective and preventive action.

Nothing in their response changed their organizational capability.

Further, there was no process or forum to monitor how well the deviation management system was working—before or after changes to the system were made. There were no management reviews of quality system performance metrics, and there was no attempt to verify whether they had actually fulfilled their commitment to the FDA.

They had to learn about their failure from the FDA.

The net effect was a continuation of inadequate data gathering, misjudged root cause, poorly written investigations, misguided CAPAs—and the same persistent nonconformities. (Need I mention a mountainous backlog of deviation reports and unpredictable product supply?)

So who are the guilty?

I think that the GM and the head of quality assurance equally share the blame.

The GM is certainly responsible for the overall capability of the organization. However, the head of quality assurance is responsible for reporting on the health and welfare of the quality system—and, he/she should possess no less than the skills of the head of marketing to get the right metrics to the right people at the right time to take action on data-driven decisions.

But, alas—most of us in QA are nerds.

 The QA Pharm

1 comment:

  1. No individual person is guilty, but the system is.