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System: QMS ISO 9001 (2008)‐QMSMDD ISO 13485 (2003)
Assessment Report/Checklist
Form 009
Iranian Blood Research and Fractionation Holding
CLIENT‐ORGANIZATION (NAME):
Company (IBRF)
Sheikh Fazlollah Exp. Way # shaheed Hemmat,
PHYSICAL LOCATION(s):
Tehran, Iran
Stage II Audit Date(s): 15,16 Jun 2016
Stage I Audit Date(s): 14‐15 May 2016
NAICS (or NACE) CODE IVD0102, IVD0103, 32.5
EXCLUSIONS:
7.3‐7.5.1.2.2‐7.5.1.2.3‐7.5.2.(1)‐7.5.4‐8.2.4.2
Assessment objectives: Third party assessment of requirements of QMS ISO
9001 (2008)‐QMSMDD ISO 13485 (2003), is met in
companies management system, as well as legal
requirements
ASSESSMENT TEAM INFORMATION
Assessment Team Leader, ATL M.R.Khoshgoo
Assessor 2 Marjan Azadmanesh
Assessor 3 Kamran Guity As TE
Assessor 4
Assessor 5
Assessor 6
Note: Adjusting the language within this form to the type of activity and nature of the organization is acceptable.
Clause observation
We pursuit to assure that client‐organization adheres to the protection of communities and consumers. This is to follow the intent to
1 the substitution of the word “identify” to the word “determine” as part of the importance to the processes being capable of achieving
desired outputs (including consumer’s well‐being).
2 Scope of activities: brator and controls. and exporting normal and hyper immune plasma to foreign fr
BRSM requires that the organization’s legal obligations and regulatory are met. Technical
Legal status supervisor is main responsible for executing and monitoring of these regulations
ok
3
Obligatory applicable standard which
organization has to follow
MOH regulations, IBTO regulation
4 Quality Management System
sample of organization processes: 'warehousing', with process indicator/index: 'No.
of Defects in warhousing', acceptance level/critteria: 'less than 5 percent', Owner
of the Process: 'warehouse manager', and 'manufacturing' is input to this process .
Output form this process is used in 'manufacturing' .next process is 'Purchasing',
Quality Management with process indicator/index: 'on time purchasing', acceptance level/critteria:
4.1 Ok
System 'more than 85%', Owner of the Process: 'trade deputy', and 'manufacturing' is input
to this process . Output form this process is used in 'manufacturing' .next process
is 'HRM', with process indicator/index: 'fulfillment of plans', acceptance
level/critteria: 'more than 90%', Owner of the Process: 'HRM deputy', and 'staff' is
input to this process . Output form this process is used in 'training suppliers' .next
process is 'QA', with process indicator/index: 'delay in Internal audit', acceptance
level/critteria: 'less than one week', Owner of the Process: 'QA manager', and 'all
processes' is input to this process . Output form this process is used in 'all
processes' .The structure of the documentation is compatible with standard
requirements regarding size and complexity of organization. the Quality Manual:
Documentation requirements MA‐01‐03 is in place, Quality Objectives: MA‐01‐04 and Policy: MA‐01‐02 backed OK
with documented procedures and work instructions/SoPs, control forms and
planing records, as well as Regulatory documents , such as; 'Recall workinstruction'
are in place.
5 Management responsibility
the Top Management, Dr.. Sedaghat Rad has communicated to the organization the
Management importance of meeting customer as well as statutory and regulatory requirements,
5.1,2
Commitment/Customer Focus through policy, objectives and providing resources
5.4 Quality Objectives OK
5.5 Responsibility, Authority and Communication
Clause observation
Top management has defined responsibilities and authorities which are
documented and communicated within the organization.Top management has
established the interrelation of all personnel affecting quality, with independence
and authority necessary to perform their tasks. as seen in O‐Chart:MA‐01‐06, to
5.5.1 Responsibility and Authority
meet IMED regulations Maryam Vafajoo Dianati has been appointed as Technical
Supervisor. with Licence number: 1/94242/ص/فلاTop Management has appointed
Mrs. Dr. Sedaghat Radas Management representative. some of the main job duties
of MR are as follows: , Establish and Implement processes needed for the QMS and OK
maintained, Report to top management on the performance of the quality
5.5.2 Management Representative management system and any need for improvement , promotion of awareness of
regulatory and customer requirements throughout the organization., Internal
communications are mostly; verbaly, Face to Face, In writing, Via
automation/email, The communication is effective and efficient according to the
5.5.3 Internal Communication complicatons and size of organization.
5.6 Management review
The latest management review was conducted on 25 may 2016Records of
Management review minutee observed,Management review was recorded
5.6.1 Management review in IBRF‐MD‐212‐FRM‐01. Participants in the latest Management review
session: Eng. Sagharchi and Dr. sedaghat rad and Dr. zeynali and eng.
Amirloo.all inputs to management review were reviewed such as Customer
feedback, product conformity, Status of preventive and corrective actions,
Follow‐up actions from previous management reviews, changes and OK
5.6.2 Review input
improvements and regulatory updates. following items has been significant
outputs of Management review: Expansion of warehouse area, preparing
CRM software. Management Review sessions are held every 12 months.
5.6.3 Review output
6 Resource Management
Trining and competence of staff affecting quality is directed by Training
procedure with Document ID of HR‐01‐01, Version:00 issued in 20 april
6.1 Provision of Resources 2016 , approved by HR manager. records of qualifications and competence
needed for positions affecting quality observed during audit; training
plan/matrix HR‐002. records of trainings conducted for positions affecting
quality observed during audit; training plan HR‐002. records of trainings
evaluations for training conducted observed during audit; evaluation
6.2 Human Resources training form HR‐005. The organization keeps the educational records of
staff affecting quality, Type of Record:BS, Ms., phd. The organization keeps
the Training records of staff affecting quality, Type of Record:Training
Clause observation
Certificates. The organization keeps the Experience and skills records of staff
affecting quality, Type of Record:Resumes. for sample, following evidence
has been reviewed during HR audit; Name of the staff profile reviewed
,Zahra Damirchi, Position: dispatch foreman/ east warehouse manager.
Education record was in place: MD of hematology. Training planned
observed during audit for GMP , Planned in December 2015. Records of
6.2.1 responsibilities Training conducted in 25 April 2016, observed during audit for QMS MDD
ISO 13485:2016 basics and documentation. Records of Training
effectiveness evaluation done in 29 April 2016 observed during audit for
QMS MDD ISO 13485:2016 basics and documentation, evaluation result:
0.92. Name of the staff profile reviewed ,Pourya Talaiee, Position: culturing OK
operator. Education record was in place: Master of scinece of microbiology.
Training planned observed during audit for GMP , Planned in December
2015. Records of Training conducted in 10 jan 2016, observed during audit
for GMP . Records of Training effectiveness evaluation done in 12 jan 2016,
observed during audit for GMP , evaluation result: 100. Name of the staff
profile reviewed ,Azade Toohidi, Position: culturing operator. Education
record was in place: Master of scinece of microbiology. Training planned
observed during audit for GMP , Planned in December 2015. Records of
Training conducted in 10 jan 2016, observed during audit for GMP . Records
of Training effectiveness evaluation done in 12 jan 2016 observed during
6.2.2 mpetence, Awareness, and Trai naudit for GMP , evaluation result: 100.
Clause observation
Preventive maintenance of machines affecting quality is directed by
Preventive Maintenance procedure with Document ID of control of
equipment and calibration, Version:EG‐114‐PRD‐01 issued in 20 april 2016 ,
approved by . records of Planned maintenance and services needed for
Machines affecting quality observed during audit; PREVENTIVE
MAINTENANCE PLAN . records of services and repairs done for Machines
affecting quality observed during audit; laminair hood culture media
production. Each machine has a record of the history of repairs and services
done for it recorded in repair log.Each machine is identified when is out of
work recorded in Repair tag. Sample of Machines taken as evidence during
audit.Name of the machine/device reviewed :laminair hood, Machine ID:
culture media production. This machine/device is used fo culture media
6.3 Infra structure production. planned Services considered for this machine observed during OK
audit: exchange of filter HEPA, Planned intervals: every after particle
counting Months. Name of the machine/device reviewed :piping of filling
device, This machine/device is used fo filling of vials. planned Services
considered for this machine observed during audit: check of pristaltic pump
and pipng, Planned intervals: every use days. Records of repairs, observed
during audit: check of pristaltic pump and pipng.
7 Product Realization
Clause observation
The organization has planned and developed the processes needed for
product realization. Planning of product realization is in consistent with the
requirements of the other processes of the quality management system.
In planning product realization, the organization has determined the
following: Quality objectives and requirements for the product; processes,
documents, and resources specific to the product; required verification,
validation, monitoring, inspection and test activities specific to the product
and the criteria for product acceptance which is explained further in the
report. The output of this planning is suitable for the organization’s method
of operations. Risk management procedure is the name of the documented
requirement established for risk management throughout product
realizatin, With Document code/Version; QA‐02‐02 approved by MD, Date;
6‐3‐16. Members of the Risk assessment team/committee; technical
supervisor , QC manager , production manager. according to Risk
management procedure, Risk levels have been considered as follows;
Intolerable risk level is: 50, and Acceptable risk level is: more than 50.
sample of risks hazards evaluated by organization: , sample 1, Hazrd: failure
7.1 Planning of product realization OK
filter of clean room, RPN / Risk Level: 72, Control Method: preventive
maintenance, RPN / Risk Level after control: less than 50, sample 2, Hazrd:
no appropriate labeling, RPN / Risk Level: 64, Control Method: final control
of labeling, RPN / Risk Level after control: less than 50, sample 3, Hazrd: hole
in tubing of filling device, RPN / Risk Level: more than 50, Control Method:
periodic visits of hosing deviceRPN / Risk Level after control: less than 50
7.2 Customer‐Related Processes
Clause observation
The company reviews the product requirements through formal
documented comunications with customer. The documented record
observed during assessment for product requirement was; #155 of order
record on sales software,dated 14 march 2016 (1394/12/22), for customer:
IBTO, sample of requested product requirements: anti Human globolin
(number 3000) before 18 march 2016, and also The company reviews the
product requirements through informal comunications or verbally with
Review of requirements customer. on sales software record #155 company sent 111 from batch 02,
7.2.2 OK
related to the product/service 2072 from batch 03 and 817 from batch 04 to the customer on 14th march
2016, Where product requirements are changed, the organization prperly
ensures that relevant documents are amended and that relevant personnel
are made aware of the changed requirements.
7.3 Design and Development
Design and Development Excluded
7.3.1 E
Planning
Design and Development Excluded
7.3.2 E
Inputs
Design and Development Excluded
7.3.3 E
Outputs
Design and development Excluded
7.3.4 E
review
Excluded
Design and development
7.3.5 E
verification
Excluded
Design and development
7.3.6 E
validation
Excluded
Control of design and
7.3.7 E
development changes
7.4 Purchasing
Clause observation
The organization has established documented procedure to ensure that
purchased product conforms to specified purchase requirements in; Purchase
and supplier evaluation procedure, with Document ID: CA‐03‐02, approved
by MD, Date; 20 April 2016. The organization evaluates and selects suppliers
based on their ability to supply product in accordance with the organization’s
requirements, the Criteria for selection, evaluation and re‐ evaluation has
been established , The organization evaluates suppliers periodically, for
grade: 'a' every 12 months, and suppliers, in grade: 'b' every
6 months, and suppliers, in grade: 'c' every 6 months, Latest suppliers
evaluation has been done in 03 march 2016. , Records of suppliers'
7.4.1 Purchasing Process evaluation was provided in CA‐043 for service providers and CA‐042 for OK
other providers. sample of criteria: quality ‐ responsive ‐ brand ‐ market
share ‐ sales procedure. Suppliers acceptance criteria; over 70. Sample
suppliers evaluation observed during audit; Barsad Tajhiz Parto, results of
evaluation for this supplier: Grade: 'a', 91. Sample observed ; Arina Hayat
Danesh, results of evaluation for this supplier: 79. Sample observed ; Bio
test, results of evaluation for this supplier: 82.
7.5 Production and Service Provision
7.5.1 Production and Service Provision
Information that describes the characteristics of the product, are available ,
Documented procedures, documented requirements, work instructions, and
reference materials and reference measurement procedures as necessary
are available, Suitable equipment is in place , for The implementation of
monitoring and measurement please refer to 7.6 and 8.2. The labeling
7.5.1.1 General requirements record provides data on amount manufactured and amount distributed. as OK
for Anti B , amount manufactured is: 2900ml , amount distributed is: 2900
ml
Clause observation
7.5.1.2 Control of production and service provision — Specific requirements
Acoording to production process and the nature of the product , product is
cleaned by the organization prior to sterilization and/or its use, product is
supplied non‐sterile to be subjected to a cleaning process prior to
sterilization and/or its useAs cleaning and contamination control of the
product is part of the production system, organization requires to establish
documented requirements for cleanliness of the product.The organization
Cleanliness of product and has established documented requirements for Cleanliness of product and
7.5.1.2.1 OK
contamination control contamination control in instruction for use of autoclaves to sterilization of
production dishes, with Document ID: QC‐01‐016,QC‐01‐015, approved by
technical supervisor, Date; 20 APR 2016, Sample of product cleanliness and
contamination control requirements; dishes of Cell culture production hall
on (OCT 2015). The cleanliness of product is validated , Validation
parameters: viralNC observed, records of sterilization validation by
7.5.
Installation activities Excluded E
The organization maintains records of the process parameters for the
sterilization process used for each sterilization batch. sample of observed
parameters: exchang of indicator on packing of sterilized dishes and
negative result of microbial test on surface of hood, observed in dishes
Particular requirements for sterilization verification by using of indicator has done (on Oct 2015) . The
7.5.1.3
sterile medical devices last time before prodution on (nov 2015) by using of indicator and microbial ok
test of hood surface before that (on 6 nov 2015). , Sterilization records are
traceable to each production batch of medical devices.
7.5.3 Identification and traceability
The organization has identified the product throughout product realization,
and established documented procedure. Document name: traceability and
identifing of product, Document code/version: QA‐01‐10, Approved by:
technical supervisor, Dated: Apr 2016. The organization identifies
7.5.3.1 Identification products/parts/material by 'Tagging'. The organization ensures that medical OK
devices returned to the organization are identified and distinguished from
conforming product.
7.5.3.2 Traceability
The organization has established documented procedures for traceability, it
defines the extent of product traceability and the records required.
Document name: traceability and identifing of product, Approved by:
technical supervisor. Organization controls and records the unique
identification of the product . Sample product taken: 'hanex solution', batch
7.5.3.2.1 General OK
no.: 94h16, Date produced: 05‐march‐16. Final product is traceable to
following items: Purchased Material, shift, for the sample taken it is tracked
to Purchased Material: chemical row material, shift: DAY,
Excluded
Particular requirements for
active implantable medical
7.5.3.2.2 OK
devices and implantable
medical devices
8 Measurement, analysis and improvement
The organization plans and implements the monitoring, measurement,
analysis and improvement processes needed. which includes; conformity of
the product, conformity and effectiveness of the quality management
8.1 General system, it also includes of use of analytic statistical techniques.Documented OK
procedures for implementation and control of the application of statistical
techniques is in place.
8.2 Monitoring and measurement
Clause observation
The organization monitors information relating to whether the organization
has met customer requirements.The organization has established
documented procedure for feedback system Procedure name: customer
feedback, Procedure code: CA‐05‐05 / 00, Approved by: MD, Dated: 20 april
2016. Source of customer requirements fulfilment monitoring: wesite,
8.2.1 Feedback
customers/ consumers/ moh based on CA‐017. Sample evidence observed: OK
Hejrat disturbution company which grade is79.25% and Pars Beevand which
is 83.25.
8.2.4 Monitoring and measurement of product
Clause observation
The Test criteria and quality control is documented in quality control of
produced culture media , With Document code:QC‐02‐006, Approved by:QC
manager, Dated:20 april 2016. As sample product QC recorded: 'Anti A'
observed Control criteria: 'sodium%(200‐300 meq/lit)', Method:
'biochemical tests'. Inspected by: 'QC expert', Date: 'jan 2016'., device was
calibrated. Number of items examinted: 'according to sampling
instruction'., Number of items accepted: 'all'. As sample product QC
recorded: 'ca%' observed Control criteria: 'below than 3 mg%' Inspected by:
8.2.4.1 General requirements 'QC expert', Date: 'jan 2016'. Number of items examinted: 'according to OK
sampling instruction'., Number of items accepted: 'all'.As sample product
QC recorded: 'anti human globulin' observed , Taken from batch 94HG02.
Control criteria: 'potasium(below than 10meq/lit)', Date: 'result:0.3'., device
was calibrated. Number of items examinted: '2193 vials'., Number of items
accepted: 'all'.
Excluded
Particular requirement for
active implantable medical
8.2.4.2 E
devices and implantable
medical devices
Clause observation
There is a documented procedure to identify, control and prevent
unintended use or delivery of non conforming products. Procedure name:
non conforming product procedure, Procedure code: QA‐05‐03 00,
Approved by: MD, Dated: 20 april 2016. controls and related responsibilities
and authorities for dealing with nonconforming product has been defined in
procedure.Dr. zeynali is authorized to deal with non‐conforming products.
Sample non‐conforming products/records observed: for batch 95ahg02 on
may 2016. Nature of Non‐conformity of the product is recorded, mis‐result
on this batch has been observed by customer. The non‐conforming product
observed in: 'Customer's site'. the non‐conforming products are properly
identified throughout the process.the organization takes actions to
eliminate the detected nonconformity and re‐verifies the product to be
conforming to requirements.The organization releases the non‐conforming
Control of nonconforming
8.3 product if it meets regulatory requirements . the non‐conforming products OK
product
are properly released by designated person. released by: Mr. reevandi qc
manager. When nonconforming product is detected after delivery or use
has started, the organization takes actions appropriate to the effects, or
potential effects, of the nonconformity. sample records of actions taken:
after investigation based on kept sample of this batch, company found out
reslut are OK and sent a letter within 48 hours to customer about result, due
verbal communication customer finds out this batch is ok without problem.
Clause observation
The organization has established documented procedures to determine,
collect and analyze appropriate data to demonstrate the suitability,
effectiveness and improvement of its quality management system.
Procedure name: Data analysis, Procedure code: da6823‐01, Approved by:
abdullah, Dated: 20 april 2016. Records of the results of the analysis of data
observed. Records observed in: data analysis report. Process name:
'warehousing', , Process index: 'No. of Defects in warhousing', Process
criteria: 'less than 5 percent', Process outcome/result: '1 %'. Process name:
'Purchasing', , Process index: 'on time purchasing', Process criteria: 'more
than 85%', Process outcome/result: '98%'. Process name: 'HRM', , Process
Analysis of data index: 'fulfillment of plans', Process criteria: 'more than 90%', Process
8.4 OK
outcome/result: '100%'. Process name: 'QA', , Process index: 'delay in
Internal audit', Process criteria: 'less than one week', Process
outcome/result: 'no delay'. with comparison of characteristics and trends of
processes with previous results the system is proved to be
improving.Corrective actions have been considered for processes not
meeting their criteria requirements.
8.5 Improvement
The organization has established documented procedures for the issue and
implementation of advisory notices. Procedure name: advisory notice and
complaints, Procedure code: QA‐05‐06, Approved by: MD, Dated: 20 april
2016. Records of all customer complaint investigations are maintained
8.5.1 General .Records of complaint investigation observed in: IBTO. the complaint OK
descreption: mis‐result on this batch has been observed by customer.
Corrective action taken: .
By exception, we indicate the specific Strengths and weakness of the organization in light of the management system, as we perceive and seen through processes in
reference to requirements of the criteria being ascribed as these apply and relate to the assessment plan and planning of the assessment. This aspect relates to
Accreditation Body as it does to the protection of consumers in the client‐organization’s role within their respective supply – chain.
Disclaimers: (1) herein, we reiterate that any suggestion or opinion that the assessment team expresses does not construe to be a contractual requirement. (2) The
degree of certainty in conclusions increases by the competence of the assessment team as well as the attestation within the assessment protocol, values, mission
and vision under which we operate for the protection of consumers, still remains a certain level of uncertainty.
Strength Weakness
experties of manufacturing staff, GMP loyality of personnel
action Request Type I Form‐008 – as we indicate and that each of the RA addresses the basic four (4) questions as seen in Form‐008:
action Request Type II Form‐008 – as we indicate and that each of the AR addresses the basic four (4) questions as seen in Form‐008: