SAP 2 Handling PT-Related Action Items – 2023 Page 1 of 6

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SAP 2

OWM PT Standard Administrative Procedure 

for 

Handling PT-Related Action Items

1 Introduction

Purpose of the Procedure 

The purpose of this procedure is to provide documented guidance for operating the 

OWM Laboratory Metrology Program – PT Program and for activities leading to 

possible action items for changes, whether corrective, minimizing risks, or 

improvements. The procedure is designed to consolidate all activities of the PT 

program in one place that might lead to these specified actions. 

Scope and References

The scope of this procedure is to cover any PT-program related activities that might 

lead to an Action Item including but not limited to the following listed items. Numbers 

in parenthesis relate to ISO/IEC 17043 and related sections in NISTIR 7214, Quality 

Manual. Unless alternative Standard Administrative Procedures (SAP) are referenced, 

this SAP covers the procedure leading to action items as well as processing the action 

items themselves. 

• Nonconforming work – may arise from any portion of the PT-program 

operations or other items on this list and leads to corrective actions (7.5.4);

• Complaints – from PT analysts, PT coordinators, or PT participants (7.6);

• Appeals – from PT participants who are dissatisfied with PT-program 

operations including decisions regarding PT analyses or other failures (7.7);

• Actions to address risk and opportunities – preventive action identified by any 

party or process (8.5); 

• Improvement actions – identified by any party or process (8.6); 

• Feedback and/or inquiries – solicited or unrequested (8.6.2);

• Corrective actions – from any party or PT-program operation (8.7); 

• Internal audits – operation internal to OWM to assess program compliance to 

requirements (see also SAP 4 for Audits and Reviews and Form 5) (8.8);

• Management reviews – operation internal to OWM periodically conducted to 

assess overall PT program operations (see also SAP 4 for Audits and Reviews

and Form 6) (8.9); and 

• Staff or participant observations identified during any PT-program operations

and/or strategic planning using a SWOT analysis (Strengths, Weaknesses, 

Opportunities, Threats);

Responsibility and Authority
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OWM Laboratory Metrology Program staff members are responsible 

for receiving, identifying, documenting, managing, reviewing 

effectiveness, and archiving actions arising from PT-program tasks on 

the list in 1.2. Staff have a responsibility to resolve action items in a 

timely manner as assigned or delegated. 

OWM Laboratory Metrology Program staff collaboratively review all 

inputs, observations, proposed action items, proposed resolutions, 

assignments, and proposed deadlines to ensure the PT program operates 

according to the PT program quality management system documents

and to ensure that all action items are resolved in a timely manner.

Feedback, complaints, or appeals lead to immediate receipt notifications 

regarding receipt (within one week) by the receiving staff member 

(assigned staff member in the case that more staff are included in 

original communications). 

Final resolution and approval of action item completion and assessment 

of effectiveness reside with the Laboratory Metrology Program Leader

after suitable team reviews. Resolutions related to a complaint, inquiry, 

or appeal will be communicated to any interested or affected party by 

the Program Leader. In the case of an appeal that was raised to a higher 

level than the Laboratory Metrology Program, the communication may 

be drafted by the Laboratory Metrology Program staff with 

communications sent by the OWM Chief. 

2 Methodology

All inputs are documented on Form 4, even if not leading to an Action Item. 

Exception: See item 2.3.1.

Enter the name and date of the person completing the form as well as the Source 

of the information to be used.

Identify the Action Type as Corrective, Risk Minimization (Preventive), 

Improvement, or Not Applicable as an action item. 

Not Applicable. Feedback or inquiries submitted as PT-program 

feedback might simply be praise – and in that case, the item is marked 

as Not Applicable. Feedback is passed on to OWM management and 

saved electronically in a PT-program feedback directory. Responses 

regarding the feedback and inquiries are saved as well. Criteria should 

be noted as Meets Criteria or Comment. The remainder of the form 

should be considered, as even positive feedback might provide a useful 

item in the Management Review, opportunities for identifying program 

strengths in strategic planning SWOT analyses, promotional newsletter 

articles or papers and so on. Inquiries require return communications 

and are evaluated to determine if program documents, criteria, or reports 
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should be further clarified to explain some aspect of the PT program. 

(All feedback is not required to be documented on Form 4 but shall be 

saved to a PT program feedback directory. This is the only Action Type 

deemed Not Applicable that does not require completion of Form 4. Full 

analysis of feedback is required for the Management Review.)

Corrective Action. Nonconforming work requires corrective action, 

whether identified by staff observations, participant complaints, 

appeals, internal audits, management reviews, or any other program 

operation.

Risk Minimization (Preventive Action). Potential failures or potential 

corrective action are identified as risks or preventive action. 

Improvement Action. Areas or items for improvement might include 

items like improving document formatting, timing on reviews, 

opportunities in strategic planning, audits, and management reviews. 

Complaints, Appeals, and Staff Observations often require a full 

assessment before identifying the Action Type as corrective, risk 

minimization (preventive), or not applicable assigning subsequent 

priorities. In that case, come back to this identifying step after 

completing the item description and assessments. In the case of Internal 

Audits and Management Reviews, the full assessment may be required 

as well, but in that case see the SAP 4 for Audits and Reviews. 

Identify the assessment. An assessment is made based on all PT-program 

quality documents and references as OK) Meets Criteria X) Does Not Meet 

Criteria or C) Comment. The decision regarding OK status must have program 

staff consensus or third party assessment. The status of an assessment as X is 

considered a nonconforming and requires explicitly identifying which 

document or reference is not complying, identifying how compliance is not met, 

and requires Corrective Action as noted in 2.3.2. Comments are unrelated to 

documented criteria or may be warnings (risk) or opportunities for 

improvement that are not currently nonconforming. 

Prioritize the action. Actions are prioritized as 1) High, 2) Medium, or 3) Low. 

The following examples provide guidance, but each item must be assessed 

based on the overall PT program operations and output. 

Examples of High priorities include many complaints, all appeals, all 

technical errors in templates for PT analysis, technical amendments 

required for PT final reports, and any PT-program operations that 

impact the quality of the program outputs (PT reports). 
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Examples of Medium priorities include all action items that will resolve 

some complaints that are related to administrative operations or risk 

minimization actions. Suggested updates to template documents for 

planning, analysis, and reporting may fall in this category. 

Examples of Low priorities include feedback and opportunities for 

improvement. Improving clarity in program documents that require 

extensive writing and approval processes may fall in this category with 

interim communications and guidance included as a medium priority. 

Create a Title that provides a brief description of the assessment.

Describe the Finding/Observation. Provide detailed explanations of what the 

issue or nonconformity is. Be clear and explicit enough so that when coming 

back to the issue after a period of time, it will still be clear as to the concern(s). 

Be sure to include additional categories from section 1.2 in this description so 

that they can be tagged in the action item log. 

Evaluate Risk. Any required or suggested action carries some level of risk. 

When evaluating risk, clearly identify and document possible risks. Document 

mechanisms that are already in place to mitigate risk, what additional guidance, 

job aids or tools can be used to mitigate risk. Identify the probability that a risk 

will or won’t occur and the implications or impact of the occurrence. Identify 

if other aspects of the PT program are affected and could affect the program 

systemically. Steps to mitigate high probability, high impact items carry the 

greatest priority and may require revisiting item 2.5. The level of assessment is 

conducted based on the level of criteria compliance and priority.

Root Cause. Consider possible causes for this item using a “five whys” or other 

applicable (documented) technique. Use the results of the root cause assessment 

to help identify possible actions after a suitable assessment has been conducted.

The root cause assessment should also consider whether there are additional 

systemic factors to consider. The level of assessment is conducted based on the 

level of criteria compliance and priority. 

Proposed Action. Suggest possible action that may be taken that align with 

corrective, risk minimization, improvement actions and associated root causes.

The action to be taken must suggest steps to prevent the issue from recurring

and not just “fix” the current issue. The proposed action also must assess 

whether any changes are needed in the quality management system or policies 

and procedures. Once a list of proposed actions is identified, a team meeting is 

conducted, or a draft form is circulated soliciting further inputs conducted 

among Laboratory Metrology Program staff. The purpose of the meeting or 

circulation of the draft is to discuss, concur, or offer alternatives to the 

assessment so far. Updates to the form are completed during the team meeting 

or draft reviews.
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Assign Action Item(s) and Due Date. At this point, the action item(s) is/are 

assigned to a staff member which may or may not be the person who completed 

the form so far). Due dates are scheduled and prioritized based on the priority 

assigned to the action item, to ensure completing action items without undue 

delay and reasonable allocation of staff time and resources. 

Complete the Action Item(s). Staff member works to complete the task, 

conducting interim reviews or obtaining additional inputs and feedback if/as 

needed. A due date may be flagged in the calendar system to track status, 

consider further evaluation, or request extensions.

Verify Action Item(s) and Date. Completion of the action item(s) or task(s) 

is/are verified by another staff member of the Laboratory Metrology Program, 

a summary of the final action(s) is documented by that staff member and the 

form is dated. A flag is entered into the calendar system to evaluate 

effectiveness of the action(s) at some time in the future, for example in 6 

months, 1 year, or at the next scheduled Internal Audit or Management Review.

Evaluation of Effectiveness. At the scheduled time, an evaluation of the 

effectiveness of the action(s) is/are assessed as a team discussion or group 

evaluation (may be conducted via documented mechanisms such as email). 

3 Records

Form 4, when completed, provides the full record of the associated Action 

Item(s). A summary of all action items is maintained in a Log for tracking the 

status and completion of the actions and to enable sorting for further analysis. 

The action item forms, and action item log are objective evidence that are 

analyzed and used during subsequent internal audits and management reviews. 

Sorting action items may be completed according to multiple tags for 

further assessment and more than one tag may be appropriate. E.g., 

complaints, participant feedback, nonconforming work, and corrective 

action may all be identified for a given action item. 

The regular analysis of action items may identify trends or larger 

systemic issues that may require PT program corrective or improvement 

actions. The analysis of action items should be completed and 

summarized as a part of the internal audit and summarized for the 

management review (see SAP 4, Audits and Reviews). 
SAP 2 Handling PT

-Related Action Items – 2023 Page 1 of 6 

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4 Workflow for Inputs Related to Action Items

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