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IJQRM
19,1
The current issue and full text archive of this journal is available at
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Self-audit of process
performance
Stanislav Karapetrovic
24
Received January 2001
Revised June 2001
Walter Willborn
Introduction
In our information-driven society, the planning, controlling, and improving of
quality becomes more complex and demanding. Modern technology at the
workplace, new global and local competition, strong pressures for value-added
processes and performances, and integrated management decision-making are
main factors for these changes. The meaning of ``quality'' has expanded beyond
``customer satisfaction with products and services'' to the ``creation of worth for
all stakeholders''. Overall business excellence is replacing the narrow objective
of meeting customer specifications; the performance of the whole system, and
not just its outputs, is focused on; and an array of issues, including
environment, occupational health and safety, social responsibility, corporate
finances, and human resources, must be incorporated into the management of
``quality''. The new ISO 9000: 2000 standards for quality management systems
reflect some of these advancements and higher demands. For example, instead
of the sole emphasis being on the customer needs and expectations, all
stakeholders are now concerned, including customers, suppliers, managers,
employees, local community and society, in general. Such developments
continue to challenge quality practitioners to ``master additional, modern, total
quality management approaches and integrate them into management
methods'' (Andersen, 2000). In the words of Chong (2000), only those
professionals ``who understand that quality is derived from effectively
managing systems will (be able to) provide leadership in the new millennium''.
In this paper, we consider the impact that the expanding role of quality has on
the quality audit, specifically addressing the possibility to use a self-audit for
control and improvement of process performance.
Much like all quality professionals, quality auditors will have to adapt to
new conditions and demands with higher qualifications and competence. The
new ISO 19011 standard for auditing of quality and environmental
management systems will stipulate such requirements. However, can the
effectiveness and efficiency of the quality audit be substantially improved by
simply imposing a standard and expanding it into environmental
management? Performance of auditors has come under considerable criticism
with regard to the actual value-added for clients and business in general (for
example, see Beeler, 1999 and Stamatis, 2000). Self-assessments against
business excellence models are widely considered to be more advantageous in
that respect (van der Wiele et al., 2000). On the other hand, the inability to
continuously ensure product quality still plagues the image of the ISO 9000
standards, and consequently, quality audits. In a highly publicized recent case
of sport-utility vehicle tire recall, a quality system registrar has been
apparently implicated by the tire manufacturer's top management for the
failure to identify the problem (Zuckerman, 2000). Even if such accusations are
dismissed as ``mud-slinging'' and ``blame-shifting'', and even if they are
explained by the misunderstanding of the main audit purpose (that is to verify
compliance with the appropriate standard, and not to inspect product quality),
the concerns about the audit effectiveness and its shortcomings in fostering
continuous improvement will still loom. Referring to the tire recall incident, and
supporting his doubts that a quality audit could have prevented it, Arter (2000)
states that ``auditors don't go around looking for field failures, (and) often don't
even have access to the data''. This is true, but the question is why? Is it
perhaps because they are not empowered to do so, since they are an entity
independent of the function being audited? Would it have helped if the process
owners, that is the auditees, had performed the audit themselves?
In an audit, the auditor and the auditee must cooperate in order to arrive at a
correct and reliable conclusion. The auditee is normally more familiar with the
actual process than the auditor. The auditor, on the other hand, is more
knowledgeable about the audit criteria, such as a quality management system
standard. Therefore, each party contributes to the expected value-added
component of an audit: the auditor does so by providing an independent and
objective assessment of the process strengths and weaknesses, and the auditee
by knowing how best to capitalize on the strengths and to eliminate the
weaknesses, in other words to improve the process in the most effective and
efficient way. However, in order to alleviate the problem of the external
imposition of judgment and the consequent lack of auditee motivation to
follow-up on it, innovative and strengthened approaches to auditing are
required. One such approach may involve the empowerment of the auditee to
conduct an evaluation of his/her own performance, effectively conducting a
Self-audit of
process
performance
25
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Self-audit of
process
performance
27
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Figure 1.
Self-audit concept
Self-audit of
process
performance
29
t
Figure 2.
Coordination among
different levels of
self-audit
IJQRM
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30
(Karapetrovic, 1999). In the words of the cartoon character Dilbert, the ISO
documentation binder is ``treated like a dead raccoon'' (Adams, 1997). In other
words, since total quality management requires a worker to be motivated and
empowered in the workplace, facilitating an assessment of performance by the
worker him/herself is most meaningful and effective. Owing to the need for
objectivity and consistency of judgments, this method should be augmented by
a periodic independent evaluation, which is, in effect, an audit (Goldstein, 1983;
Pasco and Brown, 1989). In difference to traditional auditing and selfassessments, which are both relatively formal and essentially off-line
methodologies, a self-audit would provide immediate or on-line feedback on
performance. Consequently, an approach that combines a quality audit with
self-assessments using benchmarked criteria, and capitalizes on the strengths
of the constituting methodologies, is necessary.
What are the relationships with other evaluation methods?
Since a self-audit is a system evaluation tool, it shares some commonalities, but
also differs in certain respects from other assessment methodologies. While
Table I presents several of such methods and brief comments on their
relationships with the self-audit, we will proceed with a discussion on
performance measurement, benchmarking, self-assessment, internal quality
audit, management review and self-inspection, in particular.
Performance measurement is a methodology that complements the selfaudit, since it focuses on identifying metrics related to business results (e.g.
quality, time, flexibility and cost (Neely et al., 1995)), and on evaluating the
actual performance with reference to developed metrics. An organization
implementing a self-audit should use a performance measurement system,
defined in Neely et al. (1995) as a ``set of metrics used to quantify the
effectiveness and efficiency of actions'', to develop indicators of performance
that are measured and analyzed in the audit process. Desired levels can be
obtained from the benchmarking process. For instance, a machinist can
measure the operation time and the rework rate and compare these indicators
with the levels achieved by the best machinist in the company. Then he/she will
examine the ways in which these rates can be improved, and implement
corrective and preventive actions to attain set levels. Similarly, the machinist's
company could decide to measure product cycle times, prototype introduction
times, as well as the defect rates, and compare them with a similar best-in-class
operation. In this sense, self-audits apply performance measurement and
benchmarking to quantify and qualify results, rather than enablers of
performance. Benchmarking may be used to identify the latter, as well.
On the other hand, the techniques of self-assessment and internal quality
audit, applied for evaluation against the requirements of BEM and ISO 9000
standards, respectively, may be used to focus on the existence, suitability and
adequacy of performance enablers. Table II illustrates some differences with
respect to internal, external and self-audits, as well as self-assessments. For
example, a machinist ensures that adequate ISO 9001 quality system
Term
Definition
Source
Comment
Inspection
Selfinspection
Assessment
Judgment or decision on
the quality, importance,
amount or value of
something
Selfassessment
Comprehensive,
systematic and regular
review of an
organization's activities
and results referenced
against a business
excellence model (BEM)
EFQM
(1999)
Quality
evaluation
Quality
surveillance
Audit
Systematic, independent
ISO 9000
and documented process
(2000)
for obtaining audit
evidence and evaluating it
objectively to determine
which agreed criteria are
fulfilled
Self-audit of
process
performance
31
(continued)
Table I.
Evaluation terms and
methodologies related
to the self-audit
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Table I.
Term
Definition
Source
Verification
Validation
Review
Activity undertaken to
determine the suitability,
adequacy and
effectiveness of the
subject matter to achieve
established objectives
ISO 9000
(2000)
Comment
procedures are documented and followed, and the existing instructions are
suitable for achieving performance goals. Otherwise, a procedural change is
requested. A self-audit is less formal and independent than an internal audit
that complies with the applicable audit standards (e.g. ISO 10011). As both are
evaluations of processes, they naturally have much in common and need
coordination for proper results. Under certain conditions, such as in a small
business and/or relatively simple processes, internal and self-audits could be
identical. In that case, the auditor and the auditee are the same person.
Naturally, a periodic assessment by an external auditor should be conducted to
verify self-audit results. These results should also be used as an input into the
management review process, which is required by the ISO 9000 standards. In
fact, incorporating the outcomes of the audit process in management review
and business planning is probably the most important feature of selfassessments that should render the self-audit more useful for continuous
improvement.
Finally, when self-audits are performed at the individual level (Figure 2),
they may be confused with self-inspections. Juran and Gryna (1993) explain the
difference between a self-inspection and a product audit. While the former is
related to the decision on whether the product conforms to specifications or not,
and is performed by the operator him/herself, the latter is conducted by a
person other than the operator and evaluates the appropriateness of inspection
decisions and criteria. In other words, self-inspections are product quality
evaluations, while self-audits are process performance evaluations. Also, while
inspectors cannot make a decision on the corrective action resulted from the
product nonconformance (Juran and Gryna, 1993), self-audits would allow
Criteria
External audit
Internal audit
Self-audit
Purpose
Quality system
registration
Control of
Identification of Attaining business
product, process, process strengths excellence through
or system
and weaknesses strengths and
improvement
opportunities
Scope
Standard
requirements
(e.g. ISO 9001)
By directive of
Specified area of
management (e.g. operational
plant/unit)
responsibility
By directive of
management and
award guidelines
Applicability
Registration
procedure
Mainly in large
multi-unit
companies
In companies of
any size or
industry
When goal is
business excellence
Client
Applicant,
customer or
registrar
Management
Auditor
Certified
professional
Appointed and
Authorized and
trained employee trained process
owner
Trained managers
(internal) or team
of experts
(external)
Auditee
Company
employees
Supervisory
management
Management and
supervisors
Auditing
process criteria
Documented,
comprehensive
evaluation and
analysis
Reporting and
follow-up
Formal report
Report to and
and follow-up
decision by
by management management
Report to
management
(internal) and
award committee
(external)
Process owner,
person in-charge
Submittal of
suggested
improvement(s)
Self-assessment
Self-audit of
process
performance
33
Table II.
Examples of
differences among
several types of audits
IJQRM
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34
only quality professionals, but also basically all employees and concerned
parties. The introduction of self-assessment methodologies should facilitate
such an increase in the scope of implementation. On the other hand, self-audits
for environmental, occupational health and safety, maintenance, ergonomic
and accounting applications may not be far-fetched, either. For further
discussion on the fundamentals of cross-discipline auditing, an interested
reader may refer to Karapetrovic and Willborn (2000).
Principles
Any transformation from traditional quality auditing to the proposed self-audit
framework requires a significant shift in responsibility and authority for
process evaluation from the auditor to the process owner. However, an abrupt
allocation of such responsibilities to the process owner, especially in
organizations which have just initiated systematic performance improvement
efforts (e.g. see Dale, 1999), may cause more harm than good. Lack of
knowledge and understanding of the audit criteria, subjective evaluations of
one's own work, and deficiencies in corrective and preventive action follow-up
are but a few examples that may be expected as a consequence of a sudden and
unprepared empowerment of the auditee to conduct self-evaluations. Therefore,
such a transformation can begin only after certain prerequisites are met.
What are the prerequisites for performing a self-audit?
According to Forsha (1992), the basic conditions for continuous improvement
are: ``identifying a problem, motivating yourself to do something about it, and
taking action''. While the introduction of the traditional auditing methodology
facilitates the attainment of the first stated condition, it is expected that selfevaluation will increase the motivation to act on the findings, and thus foster
the achievement of the second and third condition. However, improvement can
only occur if the process is stable and capable of meeting set requirements first,
in other words, if it is controlled. Since in a self-audit, the process owner
conducts the evaluation of process performance, the most important
prerequisite becomes self-control, both psychological and technical. Juran and
Gryna (1993), and later Shirley and Gryna (1998), discuss this concept in detail,
and emphasize that, in order to be in the state of self-control, process owners
must know:
.
what they are supposed to do;
.
what their actual performance has been; and
.
how to regulate their performance.
These conditions point out the need for proper training of self-auditors,
allocation of sufficient time to perform the audit, preparation of audit aids such
as checklists and scoring sheets, ensuring management support, and adequate
follow-up with respect to audit findings. Enclosed is a more detailed list of the
requirements for a successful self-audit:
.
.
.
.
Self-audit of
process
performance
35
IJQRM
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36
Figure 3.
General principles of
self-auditing
Methodology
In the following sections, general steps for the development of a self-audit
program, and required qualifications of involved parties are discussed.
How can we introduce a self-audit program?
Simplicity and informality are essential for the process owner, who is now
acting as an auditor, to readily accept the additional evaluation task.
Nevertheless, in addition to the above-mentioned general principles, an
elementary guideline for the execution of an audit may be suitable. The
complexity of such a guideline will depend on the relative complexity of the
auditing task at hand, understanding of the audit criteria (standards and
excellence models), as well as the intricacies of the evaluated process itself.
The following seven basic steps, similar to Juran and Gryna's (1993)
suggestions for the gradual introduction of self-inspections, are advisable:
(1) The purpose and benefit of a self-audit are studied and explained to
selected and/or concerned personnel. The initiative may come from the
process owner, executive management, or outsiders such as a consultant
or auditor. All questions and concerns should be addressed. If resistance
prevails, further steps should be taken to dispel any fears or perceptions
that the introduction of self-audits would be useless. This could be done
by emphasizing the benefits and positive results that are expected for
each individual involved. Take an example of a production worker who is
concerned about a possible negative result stemming from her self-audit.
Let us say that the audit shows a decrease in output productivity. In this
case, the fact that the self-audit is meant for improvement and carries no
punitive action of any kind should be underscored. The worker herself
would conduct such an audit. Being the most knowledgeable person about
her line of work, she is also the most likely person to discover areas for
improvement that would directly benefit her individually.
(2) A test project with a suitable process is conducted. The project must
include the process owner. For example, a quality champion or an
internal quality auditor may initiate a self-audit on their own work.
Experiences and results should be presented to a wider audience of
people who are considering the introduction of self-audits. The process
owner should also decide on the further self-action resulting from the
audit. If the test project is successfully completed, others should be
planned and implemented, following the principles outlined above. In
the case that there are still doubts about the usefulness of the exercise,
additional self-audits should be planned and executed.
(3) The process owner should be formally empowered and assisted without
undue interference. For example, the manager of the department in which
such an audit is planned should encourage the process owner to conduct
the audit. The manager should also offer assistance, for instance, in terms
of additional auditor training or time to analyze results. Mandating the
Self-audit of
process
performance
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38
(4)
(5)
(6)
(7)
circumstances do not warrant more than, for example two audits per
year, then so be it.
These seven steps of the self-audit process are illustrated with a flowchart in
Figure 4. The ongoing training of participants underlines all seven steps.
What are the required qualifications of participants?
The self-auditor, that is, the owner of the audited process, should be familiar
with the purpose and approaches of quality auditing, self-assessments and
benchmarking. Experience and confidence will normally come with practice.
Self-audit of
process
performance
39
Figure 4.
Self-audit program
an example
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40
Example
The following is a hypothetical case, designed to simultaneously describe a
self-audit process and to further outline the difference between a self-audit and
its traditional counterpart. As a process under evaluation, we have chosen the
traditional quality audit, conducted by the process owner (internal auditor).
Any audit is in itself a process, an integral part of an organizational
management system (Karapetrovic and Willborn, 2000), and therefore can be
examined for effectiveness and efficiency.
``Who audits me, the auditor?'' This is the question asked by an auditor, let
us call her Karla, of a hotel chain with an ISO 9001 registered quality
management system. The hotel's senior manager Mike answered: ``The auditor
of our registrar will have to assess our internal audit. Furthermore our regular
management review will have to decide if our internal audits are satisfactory.''
The internal auditor, however, wanted to assure herself prior to the external
audit and the management review, that her audits can stand-up to the ISO
10011 audit guidelines. Karla had been impressed by the self-audits both the
kitchen chef and the headwaiter had conducted. These departments had
achieved significant improvements, recognized by her recent internal audit.
The hotel manager was surprised by this plan for a ``self-audit of the audit''.
Nevertheless, having become familiar with the other two self-audits in the
hotel, there was no reason why the auditor should not proceed. Self-audit of the
internal audit process was certainly innovative and would help the hotel to
stand out among the other hotels in the chain. Having gained the manager's
support, the internal auditor proceeded as outlined in Figure 4.
Step 1, initiation, and Step 2, test project, had already been accomplished in
her case, since two self-audits had been conducted within the kitchen and
dining room departments. Step 3, planning, involved the assurance of
qualifications for performing a self-audit, which the internal auditor felt she
possessed by having participated in several self-assessments and
benchmarking projects while she was with a previous employer. This step also
included the empowerment to conduct a self-audit granted by the hotel
manager. Karla also called on the kitchen chef (Paul) and the headwaiter
(Vladimir) to assist her. Both were initially surprised, because they were used
to being Karla's auditees. But they rightly expected some personal benefits
from participating in the auditor's self-evaluation, and therefore agreed to
participate. Subsequently, Karla prepared a written self-audit plan, mainly for
informing her two assistants. The project aimed at evaluating the last two
comprehensive audits of the assistants' areas, the kitchen and the restaurant.
The main purpose was to evaluate if these recent audits had been properly
planned and executed. Naturally, it would be hard to answer this question
during the execution of internal quality audits, since both the auditor (Karla)
and the auditees (Paul and Vladimir with their staff) were under pressure to
verify ISO 9000 compliance. This time, in a much more relaxed state of mind,
the two assistants made a few suggestions to the self-audit plan, based on their
recent experiences as auditees. For instance, they suggested two afternoons
Self-audit of
process
performance
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(relatively quiet time of the day) as the scheduled time for the self-audit, as well
as drafting the audit report in point form on one page only, for brevity and
clarity.
Step 4, execution, included the preparation of a brief checklist, containing the
requirements of the ISO 10011 (1990) standard. Karla then discussed the
checklist with Paul and Vladimir, who suggested some additional questions.
For instance, they pointed out that the operations in the patisserie, for certain
food processing procedures, and training of sous-chefs were missed last time
the audit was conducted. Karla then retrieved the audit plans and checked
these with the procedure suggested by the ISO 10011 guideline. Following the
checklist, she revisited the individual phases of the internal audit, such as the
opening meeting, interviews, observations, presentation of the findings, and
follow-up measures.
The opening meeting was too time consuming, a brief memo would have
done sufficiently. It was found that the auditor had overlooked the requirement
that auditees have to be properly informed about an impending audit in their
area of responsibility. Food samples taken, as well as hotel guests selected for
the audit, were not sufficiently representative of the population. The audit was
poorly timed during the ``rush hours'' when staff members could not pay
adequate attention to the auditor's questions. In the restaurant, the auditor had
taken the position of a guest, while at the next table an important regular guest
had to be attended to. Finally, the audit report had not been sent to the auditee
prior to its submittal to management and its management review.
Step 5, report, concentrated on making notes of the findings directly in the
checklist and a brief discussion of future improvements with the assistants.
Karla informed the hotel manager that the self-audit was completed, giving full
credit to the kitchen chef and the headwaiter for their support. The manager
suggested that the self-audit should be further discussed in the next
management review meeting. Other department heads would be interested, so
that gradually a self-assessment program against a business excellence model
may evolve. This would also ease the change to the new ISO 9001 (2000)
standard, which requires continual measurement and improvement of
performance results.
During the next Step 6, follow-up, actions were taken to correct perceived
shortcomings, as well as to prevent future inconsistencies with the ISO 10011
guideline. As a result, Karla made changes to the internal quality audit plan,
strengthening, among others, the applied sampling and scheduling methods.
For the next self-audit in the kitchen and restaurant departments, she was
invited to participate and assist in internal benchmarking. The results of the
three conducted self-audits were reviewed in the hotel management meeting.
It was decided to broaden their scope to other departments, together with the
Step 7 continual review of the performance of consequent self-audits and
business plans.
Conclusions
In recent years, it has become apparent that organizations competing in any
kind of market cannot rely solely on ISO 9000 standards to meet the increasing
demands for continuous improvement and business excellence. Consequently,
the traditional quality auditing methodology designed to test quality assurance
systems against the standards falls well short of enabling performance
improvement. While there is little doubt that a system audit is an excellent tool
for independent, objective and systematic evaluation against the standard's
minimum requirements, based on professional and statistically sound
judgments, there is even less doubt that some changes are required. Among the
problems that continue to plague the audit are the lack of motivation of
participants, narrow focus on quality assurance, non-existing linkages with
business planning, and the inability to measure efficiency or at least focus on
business results. Meanwhile, self-assessments against quality award models
have gained prominence in exactly the areas where quality audits were lacking,
most importantly performance improvement. Although they cannot replace
quality audits, self-assessments possess one crucial characteristic that can
improve their more formal counterpart: self-evaluation.
In this paper, we proposed that the process owner conduct periodic selfevaluations of process performance. This concept, branded as a ``self-audit'', is
largely based on the internal quality audit and self-assessment methodology.
Its strength, compared to the conventional audit, lies in a less rigorous
evaluation, little external control of compliance with set procedures and official
guidelines, and the opportunity for joint identification of improvements in the
work place. In a small business, a self-audit may be the only practical process
evaluation method available. Here the manager, auditor, auditee and the client
are usually functions of the same person. The independence principle of the
traditional audit would require at least two internal auditors in the company,
regardless of how small it is. A self-audit is also expected to bring a solid
foundation in data collection, verification and evaluation, as well as more
objectivity to self-assessments. Apart from defining the concept of self-audit,
stating the reasons for its introduction, discussing the relationships of the selfaudit with other evaluation methodologies, and analyzing the scope of potential
application, this paper formulated the main principles of the self-audit, and
provided some of the prerequisites for the application. Subsequently, the
process of implementation was discussed and illustrated with a hypothetical
example.
Finally, further research in the area of quality auditing, aimed particularly at
improvements in efficiency and effectiveness of the methodology, is
particularly encouraged. Specifically to the self-audit concept, testing and
verification in a business environment, as well as an empirical study of the
application, are suggested. Research into the conversion from internal quality
auditing to self-auditing in different industries would also be beneficial. Of
particular interest would be an analysis of the usefulness and applicability of
the concept in small to medium sized enterprises. Furthermore, integrative
Self-audit of
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performance
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Self-audit of
process
performance
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