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SAP 4

OWM PT Standard Administrative Procedure 

for 

Audits and Reviews 

1 Introduction

Purpose of the Procedure 

The purpose of this procedure is to ensure a regular audit program for the 

OWM PT program to ensure the planning, establishing, implementing, and 

maintaining an auditing program including regular internal audits and regular 

management reviews.

Scope

The scope of this procedure applies to the internal auditing and management 

review of all aspects of the OWM PT Program to ensure compliance with 

applicable sections its quality management system and ISO/IEC 17043.

Applicable Documentary References. 

All documentary references for this procedure are listed and controlled 

in SAP 1, Document and Record Management. SAP 1 is explicitly 

referenced in the NISTIR 7214, Quality Manual. 

Responsibility and Authority 

OWM Laboratory Metrology Program staff are assigned responsibilities 

for conducting the internal audit and management review functions as 

described in this procedure and use the specified Forms to ensure all 

components of the PT program quality system are consistently and 

thoroughly addressed. 

All assigned staff are knowledgeable about quality systems in general, 

the PT-program quality system specifically, and have a demonstrated 

history of auditing knowledge and skills (resume, training records, or 

performance plan reviews). Because the PT program has a limited 

number of staff, independence is accomplished to the extent possible by 

alternating staff assignments and reviews.

The PT Administrative Team, comprised of the Regional PT 

Coordinators, PT Coordinators, PT Analysts and any mentors or 

observers for the PT are solicited to submit any applicable inputs to the 

ongoing operations of the PT program, its effectiveness, and compliance 

to the OWM policies and procedures, including impartiality, technical 

quality, and any observed nonconformities. 
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2 Methodology and Frequency

Conduct the Internal Audit using Form 5. Internal audits are required on 

planned intervals to ensure compliance to the quality management system 

documents (see SAP 1, Document and Record Management) and to ensure that 

the program is effectively implemented and maintained. The Laboratory 

Metrology Program leader will schedule and assign the internal audit or 

portions of the audit to staff during annual strategic planning sessions and 

include tasks in staff performance plans as appropriate a document review is 

conducted in odd-numbered years and a horizontal application review is 

conducted in even-numbered years as noted in the following sections. 

Define the Scope: Conduct a “document/reference” review in 

alternating odd-numbered years, completing the Document Reference 

columns on Form 5. 

2.1.1.1 In this assessment, the objective evidence column identifies 

which documents were observed along with their reference 

dates, status, or need for updating to ensure compliance. The 

objective evidence of the document review must be more 

explicit than simply restating and listing the documents. It is the 

availability and demonstration of compliance that all documents 

are in place (where are they located) and that they are up to date 

and readily available for the PT program. Following SAP 1, all 

referenced documents are reviewed at least every two years to 

ensure compliance with national and international documentary 

standards. (I.e., this includes a review of all ISO, ISO/IEC, 

ILAC, and accreditation or recognition body documents). 

Compliance with SAP 1, Document and Record Management is 

assessed as well. 

2.1.1.2 Complete draft Action Item forms (see SAP 2 and Form 4) when 

nonconformities are identified and reference the form 

identification number in the internal audit Form 5. Review all 

prior action items for their application to program 

documentation. SAP 2 provides guidance on timeliness of action 

item reviews. 

Define the Scope: conduct a horizontal “application” internal audit in 

alternating even-numbered years, completing Form 5 to identify 

objective evidence that the entire PT program is fully implemented and 

complies with PT-program quality system documents as identified in 

SAP 1 for Document and Record Management. 

2.1.2.1 Additional tasks include but are not limited to reviewing the 

following items, and any other records or objective evidence of 

PT-program compliance for the two years prior to the audit:
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• Completed forms and records;

• Directories of saved feedback and other PT operation 

communications;

• Directories of completed PT Plans and PT Analysis 

templates;

• Analysis and summary of all completed PTs and their 

success rates for pass/fail (as also used in the alternating 

year State Laboratory Workload Survey conducted by 

NCSLI Legal Metrology Committee). 

• Analysis of all action items and their effectiveness (see 

SAP 2); and 

• Final PT Reports. 

2.1.2.2 Complete draft Action Item forms (see SAP 2 and Form 4) as 

nonconformities are identified and reference the action item 

number in the internal audit form. Review all prior action items 

for their application to program implementation. SAP 2 provides 

guidance on timeliness of action item reviews.

The completed internal audits are discussed by the Laboratory 

Metrology Program staff and completed Form 5 is submitted to the 

Program Leader and retained in the applicable program network 

directories. Outputs from the Internal Audit are reviewed as part of the 

annual Management Reviews. Action items are reviewed according to 

SAP 2. 

Conduct the Management Review using Form 6 (outline). Management reviews 

are conducted at planned intervals to ensure continuing suitability, adequacy, 

and effectiveness of the program operations. The review includes evaluation of 

program policies and procedures to ensure compliance to the ISO/IEC 17043 

standard and the OWM PT-program documents. The OWM PT program 

schedules management reviews annually prior to strategic planning sessions or 

integrates the review and discussion as an integrated part of strategic evaluation 

and planning. 

Complete a draft Form 6. A staff member is assigned to complete the 

draft outline using outputs from the internal audit and other program 

data, using Form 6. Form 6 identifies all the required sections of a 

management review and the scope of the review. The assigned staff 

member will solicit inputs for the management review outline sections 

from other OWM staff and the PT Administrative Teams as described 

earlier. 

Schedule and conduct a PT-program management review meeting. 

Conduct the PT program management review meeting prior to the 

annual Laboratory Metrology Program strategic planning sessions so 

that the output of the PT program is included as a part of the SWOT 
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(strengths, weaknesses, opportunities, and threats) analyses and 

discussions. 

Complete the Summary of Management Review Outputs at the end of 

Form 6. Minutes of the management review meeting and high level 

summary of action items that are identified during the management 

review must be documented in the last section of the management 

review. Some of the items in this output section may also be summarized 

in the overall Executive Summary which is completed after the meeting 

is held. 

Complete any applicable draft Action Item forms (see SAP 2 and Form 

4) as corrective actions, risk minimization, or opportunities for 

improvement are identified and reference the action item number in the 

internal audit form. 

Complete the Executive Summary. Outlined items in the Executive 

Summary section guide the staff member in a high level review. SWOT 

assessments are included as part of the management review executive 

summary to integrate this effort into planned activities and to ensure it 

is a part of setting short-term and long-term goals.

3 Records

Communications and input received from the PT Administrative Team and 

other OWM staff members during the preparation of the internal audit and 

management review will be retained as objective evidence. 

Forms 5 and 6, when completed, provides the full record of the internal audit 

and management review that are completed annually. 

Follow up Action Item forms (Form 4) are completed as identified during both 

the internal audit and the management review. Action items are also entered 

into the action item log. 
S

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4 Workflow for Auditing and Management Reviews Related to Action Items 5

Form 1, 

Complaint 

Form

SAP 4, Audits and Reviews 

Form 5, 

Internal Audit 

Form

Form 6, 

Management 

Review Form 

(Outline) 

SAP 2, Handing PT Program 

Action Items

Form 4, 

Action Item 

Form and 

LOG

Summary and Analysis of Action 

Items; Evaluation of Effectiveness

Summary and Analysis of Action 

Items; Evaluation of Effectiveness