luciana mansolelli group compliance and audit group quality assurance

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Palestra: Quality of Investigations: Reliable Supply Chain, Manufacturing Deviations and the Human Factor

Luciana Mansolelli

Group Compliance and AuditGroup Quality AssuranceNovartis Pharmaceuticals Corporation

Some of the information contained in this presentation is confidential. Accordingly, Novartis respectfully requests confidential treatment with respect to this presentation and any related materials under the U.S Freedom of Information Act. Further, if any person (including any governmental employee) should request the opportunity to inspect, copy or otherwise obtain Novartis confidential information, Novartis requests that it be immediately notified of any such request, furnished with a copy of all written materials pertaining to such request (including the request itself) and given advance notice of any intended release so that it may, if deemed necessary or appropriate, pursue available remedies.

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Quality of InvestigationsObjectives

Process and requirements for handling deviations and Out of Specification Test Results.

Productive strategy meetings• Driving logical thinking• Operate in a team environment• Drive toward agreements and conclusions.

Soft data and hard data. Effective and efficient techniques for data collection Evaluation of data - techniques to analyze and challenge conclusions in

order to correctly identify the root cause(s). Human Error as a root cause. Appropriate corrective and/or preventive actions. Investigation report.

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Why is it important to improve the quality of Investigations?

Patient Risk

Compliance• Health Authority Requirement• Continual Quality Improvement• Effectiveness

- Eliminate recurrence – (focus on deviation reduction) • Identify root cause/most probable cause• Identify adequate/appropriate Corrective and Preventive

Actions

Efficiency

Economics

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William Edwards Deming

Quality of Investigations

ANVISA RDC 17 of 16.04.2010 Chapter V

Art. 26. All complaints and other information related to products with possible deviations in quality should be carefully investigated and recorded in accordance with written procedures. Sole paragraph. Preventive and corrective actions should be taken when quality deviation is proved.

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Health Authority Requirements (examples)


21CFR - Part 211 (Section 211.192)• “Any unexplained discrepancy (including a percentage of theoretical

yield exceeding the maximum or minimum percentages established in master production and control records) or the failure of a batch or any of its components to meets any of its specifications shall be thoroughly investigated, whether or not the batch has already been distributed. The investigation shall extend to other batches of the same drug product and other drug products that may be associated with the specific failure or discrepancy. A written record of the investigation shall be made and shall include the conclusions and follow-up.”

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21CFR - Part 820 - Quality System RegulationSubpart I - Control of nonconforming product.

“Each manufacturer shall establish and maintain procedures to control product that does not conform to specified requirements. The procedures shall address the identification, documentation, evaluation, segregation, and disposition of nonconforming product. The evaluation of nonconformance shall include a determination of the need for an investigation and notification of the persons or organizations responsible for the nonconformance. The evaluation and any investigation shall be documented.”

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Guidance for Industry: Investigating Out of Specification (OOS) Test Results for Pharmaceutical Production, 2006• “FDA Regulations require that an investigation be conducted

whenever an OOS test result is obtained (211.192). ………Even if the batch is rejected based on the OOS result, the investigation is necessary to determine if a result is associated with other batches of the same drug product or other products. Batch rejection does not negate the need to perform an investigation. The regulations require that a written record of the investigation be made, including conclusions and follow-up (211.192).”

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EU Guide to Good Manufacturing Practice for Medicinal Products - Chapter 6 Section 6.5• “Written procedures should be established and followed for

investigating critical deviations or the failure of a batch of intermediate or API to meet specifications. The investigation should extend to other batches that may have been associated with the specific failure or deviation.”

ISO 9001:2000 – Section 8.3 “Control of Nonconforming Product”• “The organization shall deal with nonconforming product by one or

more of the following ways- by taking action to eliminate the detected nonconformity;- by authorizing its use, release or acceptance under concession by a

relevant authority and, where applicable, by the customer;- by taking action to preclude its original intended use or application.”

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ISO 13485:2003 Section 8.5.3 “Preventive Action”• “The organization shall determine action to eliminate the causes

of potential nonconformities in order to prevent occurrence. Preventive action shall be appropriate to the effects of the potential problems.

• A documented procedure shall be established to define the requirements for:- by taking action to eliminate the detected nonconformity;

- by authorizing its use, release or acceptance under concession by a relevant authority and, where applicable, by the customer;

- by taking action to preclude its original intended use or application.”

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Question: How do the regulations differ?

They don’t………………

The requirements, expectations are the same, only worded differently.

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There is an expectation: Action

• To investigate deviations from procedures, process, etc.

Demonstrate “due diligence”• Dig “deep” enough

• Ensure an understanding as to why the “event” occurred and how to prevent recurrence

• Identify the root cause or most probable cause

• Identify, implement and monitor effectiveness of corrective and preventive actions

Quality Oversight Notification to Quality in a timely manner

• When to notify, how to notify, what information to document

• Appropriate Site Management/Quality...... review and approval

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Quality of InvestigationsDefinitions

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Quality of Investigations Definitions (1/3)

Deviation: Unplanned departure from an approved instruction or established standard or an unexpected observation.

Nonconformity: Non-fulfillment of a requirement. Out-of-Expectation Results (OOE): A test result that falls outside

historical, expected or previous trends/limits. Out-of-Specification Results (OOS): A test result that does not meet

established specifications or acceptance criteria. In stability testing the test result does not meet shelf life specifications.

Out of Trend (OOT): A stability result that does not follow the expected trend, either in comparison with other stability batches or with respect to previous results collected during the stability study.

Human Errors are errors or mistakes caused by humans in the GMP environment or which may have effect on GMP. Errors and mistakes might or might not lead to a GMP related incident.

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Definitions (2/3)

Incident is an event that may adversely affect the quality, safety, identity, strength, purity, availability (supply) or efficacy of a commercial product or clinical trial material and/or may compromise the Novartis Quality System and the global Novartis reputation. Any such incidents must be brought to the attention of the management through a system of sequential or concurrent notifications.

Unintentional errors against approved and communicated norms. The action (or lack of action) can be accidental or caused by lack of correct knowledge or be a consequence of incorrect knowledge. This category also includes situations where the approved norms were communicated but for some reason the individual was not aware or capable of properly executing the process or using the machine (for example not understanding the training, disturbing environment or complicated interface).


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Definitions (3/3)

Intentional mistakes (misconduct) require conscious decision (fault) of acting against approved and communicated norms which the individual had or should have had knowledge of. The mistakes can be active or passive, including situations where the individual should have known the right procedures or use of the machine/device but didn't understand the consequences of their actions or negligence. Mistake can be caused by misjudgment, carelessness, or forgetfulness. This category also includes covering-up unintentional errors.

Enforced misconducts are when individual is ordered, forced or otherwise pressured against individuals will to act against approved and communicated norms.

Hypothesis is an idea or theory that is not proven but leads to further study or discussion.

Quality of InvestigationsThe Overall Process

Event OccursNotify

SQU/ Area Management

SQUClassify/ Assign Investigate

Root Cause/ID CA/ PA

Complete I nvestigation

InvestigationReview & Approval

CA/ PA Implemented

CA/ PA Effectiveness

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The investigation process is a simple process.

It consists of:• Evaluate situation

• Collect and evaluate information

• Draw a conclusion

• Compare information

• Revisit conclusion

• Challenge conclusion

• Challenge outcome

• Re-evaluate, etc.

Quality of InvestigationsThe Investigation – Key points to consider

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Quality of InvestigationsKey points to consider

Key Steps………

A. STOP!!!!

B. Assess/Evaluate

C. Determine Next Steps

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You also stop because…… Allows for a “preservation” of the “scene.”

• Documents (Batch Records, Data Sheets, etc.)• Equipment/instruments • Glassware• Materials/Excipients• Reagents• Sample• Standard and sample solutions• Anything related to the activity

Note: It is critical that all solutions, glassware, etc. everything used in the process/analysis are retained.


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Considering Laboratory OOS investigations• Level 1 – Preliminary Investigation

- Allows for the elimination of obvious errors, i.e., Laboratory Assigned Cause- MUST be completed with 5 working days from discovery

• Level 2 – Full Scale Investigation (Quality Oversight required)- Notification to Quality and Manufacturing- MUST be completed within 30 calendar days

Important to remember• Cannot perform investigational testing, such as retests in Phase 1.

• Those activities are performed in a Phase II Investigation activity and typically require an approved plan/protocol.


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Quality of InvestigationsStrategy Meetings – Critical Success Factors

Problem statement – clearly define the issue (DEVIATION)Team Membership - who should participate

• R & D, Laboratory, Operations, Technical Services, Quality Assurance, Engineering, Others?

• Appropriate technical experience

• Availability

Scope of the meeting must be communicated in advance

• At this stage actions should be towards Data collection and Analysis Share all relevant background information

• Results in a more effective meetings by giving the attendees the opportunity to be prepared

Facilitation of the meeting to enable productive problem solving analysis

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In order to determine if the conclusion is appropriate, we must first review the objective evidence (data) that supports the conclusion.

Objective & Subjective

Hard information Soft Information(data/facts) (no data)

Hard plus Soft plus Experience = Judgment

Data Collection and Analysis

Quality of InvestigationsData Collection & Analysis

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Facts • Can be measured or photographed

Judgments, Opinions, Assumptions are not facts!

Exception: Eye Witness Reports

Example: too much, insufficient, poor …

Fact versus Theory


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Manufacturing Records (examples)• Batch records• Applicable SOPs• Equipment records• Temperature Charts , etc.• Training Records• Other?

Laboratory Records (examples)• Notebook pages/data sheets• Test Methods• Applicable SOPs• Sample Receipt

− What do I look at?− Sample characteristics

• Chromatograms, data printouts, temperature charts, etc.

• Training Records• Equipment/Instrument Records• Other?25


An interview is so important to an investigation as it may: Provide information that has not been recorded in the

notification to Quality or Add clarity to what was recorded Eye Witness.................. Provide historical data or information

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Ensure there is no “testing into compliance”……….

Quality of InvestigationsDocumentation of Investigation Activities

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• Capture all information

• Be Accurate

• Document every step of your investigation.

Root Cause AnalysisOverview

Basic Problem Solving Tools• Quality Control Tools: Run Chart, Pareto

Chart, Control Chart, Flowchart, Cause and Effect Diagram, Process Mapping

• Creativity Tools: Brainstorming, Picture and Word Associations

• Management and Planning Tools: Affinity and Tree Diagram

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Root Cause AnalysisBrainstorming

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Root Cause AnalysisProcess Mapping

Process Map• A method for displaying processes that illustrates

how a product or transaction is processed

• It is a visual representation of the work flow either within a process or an image of the whole operation

• Comprises a stream of activities that transforms a well defined input or set of inputs into a predefined set of outputs

Process mapping is useful in instances when there is a need to evaluate multiple processes, and in instances of a parallel evaluation of an analytical test method and a batch record.

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Root Cause AnalysisProcess Mapping – Visual Mapping – Example 1

Process Mapping - Test Method (word document)

• Buffer Solution: Transfer 3.48g of K2HPO4 into a 1000mL volumetric flask, dissolve, dilute with HPLC grade water to volume and mix. Filter through 0.45um PTFE filter prior to use.

• 10 mol/l KOH Solution: Weigh 56.1 of KOH pellets into 100mL volumetric flask, add 70 mL of water and shake to dissolve. Use flowing water to prevent solution from heating. Fill flask to mark with water and shake. Filter solution with 0.45um PTFE filter.

Transfer 3.48g to 1000mL volumetric

Dilute to volume with HPLC water

Filter using 0.45um PTFE filter

Weigh 56.1 KOH into 100mL volumetric, add

Water…mix

Use flowing water,to prevent heating

Filter using 0.45umPTFE filter

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Dispensing

Blending

Fluidized Bed Dryer

Coating

Tableting Packaging

Magnesium Stearate

Granulation

Sieving

Sieving

Air

Air

Scale

Root Cause AnalysisProcess Mapping – Visual Mapping – Example 2

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Root Cause AnalysisRoot Cause Analysis – Cause & Effect

What is a Fishbone diagram?• Invented by Dr. Kaoru Ishikawa• It is an analysis tool that provides systematic way of looking at effects

and the causes that may create or contribute to those effects• Creates a picture of the possible causes of the problem• Prevents the team from jumping to conclusions without evaluating and

challenging the possible causes• Helps to build support for the identified corrective and preventive action(s)

that will address the problem

When should it be used? When the “team” :• Needs to study a problem and determine the cause• Needs to study all possible reasons why a process is beginning to have

difficulties, problems or breakdowns• Needs to identify areas for data collection• Wants to study why a process is not performing properly or producing the

desired results

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Root Cause Analysis Cause & Effect – Site Example

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Root Cause Analysis 5 Whys

Why? Answer and observation

Why was Zone A contaminated by Staph. Aureus? Because operator caused contamination

Why did operator cause contamination? Because operator was not present during training regarding plant hygiene

Why was operator not present during training? Because operator was on vacation

Why was there no training follow up when he returned from vacation?

Because there is no procedure defined for follow up of missed trainings

Why was there no procedure defined for follow up of missed trainings?

The SOP was not updated to align with the requirement

Why was SOP not updated according to requirement?

Because there is not process established to ensure that all local SOPs are updated to align with new or updated Global SOPs

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Root Cause Analysis Other Tools

The qualitative tools we have just discussed are examples of those most commonly used when performing root cause analysis

There are other “Problem Solving” tools as well. For example:

Failure Mode and Effects Analysis (FMEA) Interrelationship Diagrams

Map out relationships between all possible causes Kepner Tregoe (KT) Others?

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Root Cause Analysis Kepner Tregoe Basics

IS IS NOT Distinctions Changes

WHAT • What thing or group of things is having the problem?

•What is wrong with it or them?

• What thing or group of things could be having the problem, but is not.

• What could be wrong with it or them but is not?

WHERE • Where geographically, is the thing when the problem is noticed?.

•Where is the problem located on the thing?

• Where could the thing be when the problem is noticed but is not?

• Where could the problem be located on the thing but is not?.

WHEN

• When was the problem first noticed? (date / time)

• When has the problem been noticed since the? (date/ time) Any pattern?

• When, in the history or lifecycle of the thing, was the problem first noticed?

• When could the problem have been first noticed, but was not? (date / time).

• When could the problem have been noticed since then, but was not? (date / time).

• When, in the history or lifecycle of the thing, could the problem have been first noticed but was not?

EXTENT •How many units of the thing have the problem?

•What is the size of a single defect?

• How many flaws or defects are on any one unit?

• What is the trend (in object, in defect)?

• How many units of the thing could have the problem, but do not?

• What other size could the defect be, but is not?• How many flaws or defects could be on any one unit but are not? What could the trend be but is not?

KT Matrix - Helpful Questions

What IS the deviation ?

What could be the deviation, but IS NOT ?

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Quality of Investigations Root Cause Analysis

Decision Making

Continue to search for rootcauses until

possibilities areexhausted!

Eliminate unreasonable

causes

Identify new potential causes

Gatheradditional

data

Compare causes against the facts

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Quality of Investigations Root Cause Analysis seeks to identify the CAUSE of the deviation

There are generally three types of causes:

Physical - Tangible, material items failed in some way (for example, an equipment failure occurs).

Human - People do something incorrectly, or did not doing something that was required. Human error typically leads to physical causes (for example, no one checked the fluid level, which led to the failure).

Organizational - A system, process, or procedure is faulty (for example, no one person was responsible for maintenance, and everyone assumed someone else had performed the required maintenance).

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Quality of InvestigationsHuman Factor

Human error is typically not the root cause Human errors are symptoms of deeper causes (symptom versus

the disease) We must perform in depth investigations to determine the cause of

the “Human Error”• Interviewing is the most critical step in the investigation

Key points to consider: Poor design of facility and/or equipment Inadequate procedures and processes Ineffective training Inadequate supervision Inadequate staff and resources Ineffective communication Roles and responsibilities not clearly defined

Human Error Questionnaire

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Quality of InvestigationsContributing factors of Human Error

• Processes- Inadequate checks,

verification, control

- Change in process

- Lack of robust design

- Not user tested

- No user centered design

• People - Fatigue

- Lack or loss of focus

- Stress

- Automatism

- Superman syndrome (It won’t happen to me)

- Not understanding the impact of their actions

- State of mind

- Ignore a suspected issue

- Disregards established procedures

- Circumvents the process (workarounds)

• Organization - Training

- Right people in the right roles

- Peer Pressure

- Proper Resourcing

• Governance / Metrics - Speed is more important

than right

- Quantity over Quality

- Performance Pressures

- Unclear accountability and responsibility

- Deadlines

- Budget

- Unclear / insufficient communication

• Procedures - Unclear Instructions

- Procedure doesn’t match the process

- Overly complicated

- No user-centered design

• Tools - Improper tools and

equipment

- Unnecessarily complex

• Physical Environment- Noise

- Climate

- Lighting

- Interruptions & Distractions

- Workspace design

- Cleanliness / Order

• Product

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Stepwise approach for Human Factor investigations:

• Detection of potential HFs including evaluation Skill Based Errors Rule Based Errors Knowledge Based Errors

• Investigation leading to identifying most probable root cause and contributing factors. Individual Environmental Process/interface Non Human Factors

• Consequences including CAPAs and disciplinary or administrative actions

• Follow-up

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Key elements of an Error Free Workplace:

Speak up about errors What behaviors are we driving (and how) that increase

human error? Strive for perfection in order to achieve excellence Eliminate repeat human errors Personally recognize and reward success

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Effective Corrective & Preventive Action (CAPA) and remediation management of quality, compliance and risk related issues is essential for a closed loop, continuous improvement process.

Relying on stand-alone solutions or paper-based processes to manage CAPA and remediation processes may fail to address systemic problems due to limited reach and visibility.

Corrective and Preventive ActionIntroduction

Continuous

Improvement

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Correction/Remedial Action – Actions taken to eliminate the existing nonconformity

Corrective Action - An action taken to eliminate the cause of an existing deviation, non-conformity, defect, or other undesirable situation in order to prevent recurrence. (REACTIVE)

Preventive Action – An action taken to detect and eliminate the causes of potential deviations, non-conformity or defect in order to prevent occurrence. (PROACTIVE)

• Preventive actions are actions to reduce the probability that a potential problem will occur.

Effectiveness Check – An action taken to verify that the expected results are achieved I.e., that the corrective and or preventive actions prevent occurrence or recurrence of the event. (Has the root cause of the problem been solved?)

Quality of InvestigationsDefinitions

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What does it look like?• Must be a “stand alone” document

• A “Table of Contents” is a bonus!

What is the expectation?• All relevant documentation must be included

and/or referenced as to its location

The Report• Must be clear and concise

• Contain all supporting Documentation• Raw Data

- Analytical Test Methods

- Metrics/Charts

- Batch Records

- Maintenance/Calibration Records

- Training Records, etc.

Quality of InvestigationsThe Investigation Package

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luciana mansolelli group compliance and audit group quality assurance

Documents

product quality

deming cycle

soft data

hard data

novartis requests

manufacturing deviations

root causes

japanese manufacturing