Operational Stability

At the heart of achieving consistent pharmaceutical quality lies operational stability—a fundamental concept that forms the critical middle layer in the House of Quality model. Operational stability serves as the bridge between cultural foundations and the higher-level outcomes of effectiveness, efficiency, and excellence. This critical positioning makes it worthy of detailed examination, particularly as regulatory bodies increasingly emphasize Quality Management Maturity (QMM) as a framework for evaluating pharmaceutical operations.

he image is a diagram in the shape of a house, illustrating a framework for PQS (Pharmaceutical Quality System) Excellence. The house is divided into several colored sections:

The roof is labeled "PQS Excellence."

Below the roof, two sections are labeled "PQS Effectiveness" and "PQS Efficiency."

Underneath, three blocks are labeled "Supplier Reliability," "Operational Stability," and "Design Robustness."

Below these, a larger block spans the width and is labeled "CAPA Effectiveness."

The base of the house is labeled "Cultural Excellence."

On the left side, two vertical sections are labeled "Enabling System" (with sub-levels A and B) and "Result System" (with sub-levels C, D, and E).

On the right side, a vertical label reads "Structural Factors."

The diagram uses different shades of green and blue to distinguish between sections and systems.

Understanding Operational Stability in Pharmaceutical Manufacturing

Operational stability represents the state where manufacturing and quality processes exhibit consistent, predictable performance over time with minimal unexpected variations. It refers to the capability of production systems to maintain control within defined parameters regardless of routine challenges that may arise. In pharmaceutical manufacturing, operational stability encompasses everything from batch-to-batch consistency to equipment reliability, from procedural adherence to supply chain resilience.

The essence of operational stability lies in its emphasis on reliability and predictability. A stable operation delivers consistent outcomes not by chance but by design—through robust systems that can withstand normal operating stresses without performance degradation. Pharmaceutical operations that achieve stability demonstrate the ability to maintain critical quality attributes within specified limits while accommodating normal variability in inputs such as raw materials, human operations, and environmental conditions.

According to the House of Quality model for pharmaceutical quality frameworks, operational stability occupies a central position between cultural foundations and higher-level performance outcomes. This positioning is not accidental—it recognizes that stability is both dependent on cultural excellence below it and necessary for the efficiency and effectiveness that lead to excellence above it.

The Path to Obtaining Operational Stability

Achieving operational stability requires a systematic approach that addresses several interconnected dimensions. This pursuit begins with establishing robust processes designed with sufficient control mechanisms and clear operating parameters. Process design should incorporate quality by design principles, ensuring that processes are inherently capable of consistent performance rather than relying on inspection to catch deviations.

Standard operating procedures form the backbone of operational stability. These procedures must be not merely documented but actively maintained, followed, and continuously improved. This principle applies broadly—authoritative documentation precedes execution, ensuring alignment and clarity.

Equipment reliability programs represent another critical component in achieving operational stability. Preventive maintenance schedules, calibration programs, and equipment qualification processes all contribute to ensuring that physical assets support rather than undermine stability goals. The FDA’s guidance on pharmaceutical CGMP regulation emphasizes the importance of the Facilities and Equipment System, which ensures that facilities and equipment are suitable for their intended use and maintained properly.

Supplier qualification and management play an equally important role. As pharmaceutical manufacturing becomes increasingly globalized, with supply chains spanning multiple countries and organizations, the stability of supplied materials becomes essential for operational stability. “Supplier Reliability” appears in the House of Quality model at the same level as operational stability, underscoring their interconnected nature1. Robust supplier qualification programs, ongoing monitoring, and collaborative relationships with key vendors all contribute to supply chain stability that supports overall operational stability.

Human factors cannot be overlooked in the pursuit of operational stability. Training programs, knowledge management systems, and appropriate staffing levels all contribute to consistent human performance. The establishment of a “zero-defect culture” underscores the importance of human factors in achieving true operational stability.

Main Content Overview:
The document outlines six key quality systems essential for effective quality management in regulated industries, particularly pharmaceuticals and related fields. Each system is described with its role, focus areas, and importance.

Detailed Alt Text
1. Quality System

Role: Central hub for all other systems, ensuring overall quality management.

Focus: Management responsibilities, internal audits, CAPA (Corrective and Preventive Actions), and continuous improvement.

Importance: Integrates and manages all systems to maintain product quality and regulatory compliance.

2. Laboratory Controls System

Role: Ensures reliability of laboratory testing and data integrity.

Focus: Sampling, testing, analytical method validation, and laboratory records.

Importance: Verifies products meet quality specifications before release.

3. Packaging and Labeling System

Role: Manages packaging and labeling to ensure correct and compliant product presentation.

Focus: Label control, packaging operations, and labeling verification.

Importance: Prevents mix-ups and ensures correct product identification and use.

4. Facilities and Equipment System

Role: Ensures facilities and equipment are suitable and maintained for intended use.

Focus: Design, maintenance, cleaning, and calibration.

Importance: Prevents contamination and ensures consistent manufacturing conditions.

5. Materials System

Role: Manages control of raw materials, components, and packaging materials.

Focus: Supplier qualification, receipt, storage, inventory control, and testing.

Importance: Ensures only high-quality materials are used, reducing risk of defects.

6. Production System

Role: Oversees manufacturing processes.

Focus: Process controls, batch records, in-process controls, and validation.

Importance: Ensures consistent manufacturing and adherence to quality criteria.

Image Description:
A diagram (not shown here) likely illustrates the interconnection of the six quality systems, possibly with the "Quality System" at the center and the other five systems branching out, indicating their relationship and integration within an overall quality management framework

Measuring Operational Stability: Key Metrics and Approaches

Measurement forms the foundation of any improvement effort. For operational stability, measurement approaches must capture both the state of stability and the factors that contribute to it. The pharmaceutical industry utilizes several key metrics to assess operational stability, ranging from process-specific measurements to broader organizational indicators.

Process capability indices (Cp, Cpk) provide quantitative measures of a process’s ability to meet specifications consistently. These statistical measures compare the natural variation in a process against specified tolerances. A process with high capability indices demonstrates the stability necessary for consistent output. These measures help distinguish between common cause variations (inherent to the process) and special cause variations (indicating potential instability).

Deviation rates and severity classification offer another window into operational stability. Tracking not just the volume but the nature and significance of deviations provides insight into systemic stability issues. The following table outlines how different deviation patterns might be interpreted:

Deviation Pattern	Stability Implication	Recommended Response
Low frequency, low severity	Good operational stability	Continue monitoring, seek incremental improvements
Low frequency, high severity	Critical vulnerability despite apparent stability	Root cause analysis, systemic preventive actions
High frequency, low severity	Degrading stability, risk of normalization of deviance	Process review, operator training, standard work reinforcement
High frequency, high severity	Fundamental stability issues	Comprehensive process redesign, management system review

Equipment reliability metrics such as Mean Time Between Failures (MTBF) and Overall Equipment Effectiveness (OEE) provide visibility into the physical infrastructure supporting operations. These measures help identify whether equipment-related issues are undermining otherwise well-designed processes.

Batch cycle time consistency represents another valuable metric for operational stability. In stable operations, the time required to complete batch manufacturing should fall within a predictable range. Increasing variability in cycle times often serves as an early warning sign of degrading operational stability.

Right-First-Time (RFT) batch rates measure the percentage of batches that proceed through the entire manufacturing process without requiring rework, deviation management, or investigation. High and consistent RFT rates indicate strong operational stability.

Leveraging Operational Stability for Organizational Excellence

Once achieved, operational stability becomes a powerful platform for broader organizational excellence. Robust operational stability delivers substantial business benefits that extend throughout the organization.

Resource optimization represents one of the most immediate benefits. Stable operations require fewer resources dedicated to firefighting, deviation management, and rework. This allows for more strategic allocation of both human and financial resources. As noted in the St. Gallen reports “organizations with higher levels of cultural excellence, including employee engagement and continuous improvement mindsets supports both quality and efficiency improvements.”

Stable operations enable focused improvement efforts. Rather than dispersing improvement resources across multiple priority issues, organizations can target specific opportunities for enhancement. This focused approach yields more substantial gains and allows for the systematic building of capabilities over time.

Regulatory confidence grows naturally from demonstrated operational stability. Regulatory agencies increasingly look beyond mere compliance to assess the maturity of quality systems. The FDA’s Quality Management Maturity (QMM) program explicitly recognizes that mature quality systems are characterized by consistent, reliable processes that ensure quality objectives and promote continual improvement.

Market differentiation emerges as companies leverage their operational stability to deliver consistently high-quality products with reliable supply. In markets where drug shortages have become commonplace, the ability to maintain stable supply becomes a significant competitive advantage.

Innovation capacity expands when operational stability frees resources and attention previously consumed by basic operational problems. Organizations with stable operations can redirect energy toward innovation in products, processes, and business models.

Operational Stability within the House of Quality Model

The House of Quality model places operational stability in a pivotal middle position. This architectural metaphor is instructive—like the middle floors of a building, operational stability both depends on what lies beneath it and supports what rises above it. Understanding this positioning helps clarify operational stability’s role in the broader quality management system.

Cultural excellence lies at the foundation of the House of Quality. This foundation provides the mindset, values, and behaviors necessary for sustained operational stability. Without this cultural foundation, attempts to establish operational stability will likely prove short-lived. At a high level of quality management maturity, organizations operate optimally with clear signals of alignment, where quality and risk management stem from and support the organization’s objectives and values.

Above operational stability in the House of Quality model sit Effectiveness and Efficiency, which together lead to Excellence at the apex. This positioning illustrates that operational stability serves as the essential platform enabling both effectiveness (doing the right things) and efficiency (doing things right). Research from the St. Gallen reports found that “plants with more effective quality systems also tend to be more efficient in their operations,” although “effectiveness only explained about 4% of the variation in efficiency scores.”

The House of Quality model also places Supplier Reliability and Design Robustness at the same level as Operational Stability. This horizontal alignment stems from these three elements work in concert as the critical middle layer of the quality system. Collectively, they provide the stable platform necessary for higher-level performance.

Element	Relationship to Operational Stability	Joint Contribution to Upper Levels
Supplier Reliability	Provides consistent input materials essential for operational stability	Enables predictable performance and resource optimization
Operational Stability	Creates consistent process performance regardless of normal variations	Establishes the foundation for systematic improvement and performance optimization
Design Robustness	Ensures processes and products can withstand variation without quality impact	Reduces the resource burden of controlling variation, freeing capacity for improvement

The Critical Middle: Why Operational Stability Enables PQS Effectiveness and Efficiency

Operational stability functions as the essential bridge between cultural foundations and higher-level performance outcomes. This positioning highlights its critical role in translating quality culture into tangible quality performance.

Operational stability enables PQS effectiveness by creating the conditions necessary for systems to function as designed. The PQS effectiveness visible in the upper portions of the House of Quality depends on reliable execution of core processes. When operations are unstable, even well-designed quality systems fail to deliver their intended outcomes.

Operational stability enables efficiency by reducing wasteful activities associated with unstable processes. Without stability, efficiency initiatives often fail to deliver sustainable results as resources continue to be diverted to managing instability.

The relationship between operational stability and the higher levels of the House of Quality follows a hierarchical pattern. Attempts to achieve efficiency without first establishing stability typically result in fragile systems that deliver short-term gains at the expense of long-term performance. Similarly, effectiveness cannot be sustained without the foundation of stability. The model implies a necessary sequence: first cultural excellence, then operational stability (alongside supplier reliability and design robustness), followed by effectiveness and efficiency, ultimately leading to excellence.

Balancing Operational Stability with Innovation and Adaptability

While operational stability provides numerous benefits, it must be balanced with innovation and adaptability to avoid organizational rigidity. There is a potential negative consequences of an excessive focus on efficiency, including reduced resilience and flexibility which can lead to stifled innovation and creativity.

The challenge lies in establishing sufficient stability to enable consistent performance while maintaining the adaptability necessary for continuous improvement and innovation. This balance requires thoughtful design of stability mechanisms, ensuring they control critical quality attributes without unnecessarily constraining beneficial innovation.

Process characterization plays an important role in striking this balance. By thoroughly understanding which process parameters truly impact critical quality attributes, organizations can focus stability efforts where they matter most while allowing flexibility elsewhere. This selective approach to stability creates what might be called “bounded flexibility”—freedom to innovate within well-understood boundaries.

Change management systems represent another critical mechanism for balancing stability with innovation. Well-designed change management ensures that innovations are implemented in a controlled manner that preserves operational stability. ICH Q10 specifically identifies Change Management Systems as a key element of the Pharmaceutical Quality System, emphasizing its importance in maintaining this balance.

Measuring Quality Management Maturity through Operational Stability

Regulatory agencies increasingly recognize operational stability as a key indicator of Quality Management Maturity (QMM). The FDA’s QMM program evaluates organizations across multiple dimensions, with operational performance being a central consideration.

Organizations can assess their own QMM level by examining the nature and pattern of their operational stability. The following table presents a maturity progression framework related to operational stability:

Maturity Level	Operational Stability Characteristics	Evidence Indicators
Reactive (Level 1)	Unstable processes requiring constant intervention	High deviation rates, frequent batch rejections, unpredictable cycle times
Controlled (Level 2)	Basic stability achieved through rigid controls and extensive oversight	Low deviation rates but high oversight costs, limited process understanding
Predictive (Level 3)	Processes demonstrate inherent stability with normal variation understood	Statistical process control effective, leading indicators utilized
Proactive (Level 4)	Stability maintained through systemic approaches rather than individual efforts	Root causes addressed systematically, culture of ownership evident
Innovative (Level 5)	Stability serves as platform for continuous improvement and innovation	Stability metrics consistently excellent, resources focused on value-adding activities

This maturity progression aligns with the FDA’s emphasis on QMM as “the state attained when drug manufacturers have consistent, reliable, and robust business processes to achieve quality objectives and promote continual improvement”.

Practical Approaches to Building Operational Stability

Building operational stability requires a comprehensive approach addressing process design, organizational capabilities, and management systems. Several practical methods have proven particularly effective in pharmaceutical manufacturing environments.

Statistical Process Control (SPC) provides a systematic approach to monitoring processes and distinguishing between common cause and special cause variation. By establishing control limits based on natural process variation, SPC helps identify when processes are operating stably within expected variation versus when they experience unusual variation requiring investigation. This distinction prevents over-reaction to normal variation while ensuring appropriate response to significant deviations.

Process validation activities establish scientific evidence that a process can consistently deliver quality products. Modern validation approaches emphasize ongoing process verification rather than point-in-time demonstrations, aligning with the continuous nature of operational stability.

Root cause analysis capabilities ensure that when deviations occur, they are investigated thoroughly enough to identify and address underlying causes rather than symptoms. This prevents recurrence and systematically improves stability over time. The CAPA (Corrective Action and Preventive Action) system plays a central role in this aspect of building operational stability.

Knowledge management systems capture and make accessible the operational knowledge that supports stability. By preserving institutional knowledge and making it available when needed, these systems reduce dependence on individual expertise and create more resilient operations. This aligns with ICH Q10’s emphasis on “expanding the body of knowledge”.

Training and capability development ensure that personnel possess the necessary skills to maintain operational stability. Investment in operator capabilities pays dividends through reduced variability in human performance, often a significant factor in overall operational stability.

Operational Stability as the Engine of Quality Excellence

Operational stability occupies a pivotal position in the House of Quality model—neither the foundation nor the capstone, but the essential middle that translates cultural excellence into tangible performance outcomes. Its position reflects its dual nature: dependent on cultural foundations for sustainability while enabling the effectiveness and efficiency that lead to excellence.

The journey toward operational stability is not merely technical but cultural and organizational. It requires systematic approaches, appropriate metrics, and balanced objectives that recognize stability as a means rather than an end. Organizations that achieve robust operational stability position themselves for both regulatory confidence and market leadership.

As regulatory frameworks evolve toward Quality Management Maturity models, operational stability will increasingly serve as a differentiator between organizations. Those that establish and maintain strong operational stability will find themselves well-positioned for both compliance and competition in an increasingly demanding pharmaceutical landscape.

The House of Quality model provides a valuable framework for understanding operational stability’s role and relationships. By recognizing its position between cultural foundations and performance outcomes, organizations can develop more effective strategies for building and leveraging operational stability. The result is a more robust quality system capable of delivering not just compliance but true quality excellence that benefits patients, practitioners, and the business itself.

Integrating Elegance into Quality Systems: The Third Dimension of Excellence

Quality systems often focus on efficiency—doing things right—and effectiveness—doing the right things. However, as industries evolve and systems grow more complex, a third dimension is essential to achieving true excellence: elegance. Elegance in quality systems is not merely about simplicity but about creating solutions that are intuitive, sustainable, and seamlessly integrated into organizational workflows.

Elegance elevates quality systems by addressing complexity in a way that reduces friction while maintaining sophistication. It involves designing processes that are not only functional but also intuitive and visually appealing, encouraging engagement rather than resistance. For example, an elegant deviation management system might replace cumbersome, multi-step forms with guided tools that simplify root cause analysis while improving accuracy. By integrating such elements, organizations can achieve compliance with less effort and greater satisfaction among users.

When viewed through the lens of the Excellence Triad, elegance acts as a multiplier for both efficiency and effectiveness. Efficiency focuses on streamlining processes to save time and resources, while effectiveness ensures those processes align with organizational goals and regulatory requirements. Elegance bridges these two dimensions by creating systems that are not only efficient and effective but also enjoyable to use. For instance, a visually intuitive risk assessment matrix can enhance both the speed of decision-making (efficiency) and the accuracy of risk evaluations (effectiveness), all while fostering user engagement through its elegant design.

To imagine how elegance can be embedded into a quality system, consider this high-level example of an elegance-infused quality plan aimed at increasing maturity within 18 months. At its core, this plan emphasizes simplicity and sustainability while aligning with organizational objectives. The plan begins with a clear purpose: to prioritize patient safety through elegant simplicity. This guiding principle is operationalized through metrics such as limiting redundant documents and minimizing the steps required to report quality events.

The implementation framework includes cross-functional quality circles tasked with redesigning one process each quarter using visual heuristics like symmetry and closure. These teams also conduct retrospectives to evaluate the cognitive load of procedures and the aesthetic clarity of dashboards, ensuring that elegance remains a central focus. Documentation is treated as a living system, with cognitive learning driven and video micro-procedures replacing lengthy procedures and tools scoring documents to ensure they remain user-friendly.

The roadmap for maturity integrates elegance at every stage. At the standardized level, efficiency targets include achieving 95% on-time CAPA closures, while elegance milestones focus on reducing document complexity scores across SOPs. As the organization progresses to predictive maturity, AI-driven risk forecasts enhance efficiency, while staff adoption rates reflect the intuitive nature of the systems in place. Finally, at the optimizing stage, zero repeat audits signify peak efficiency and effectiveness, while voluntary adoption of quality tools by R&D teams underscores the system’s elegance.

To cultivate elegance within quality systems, organizations can adopt three key strategies. First, they should identify and eliminate sources of systemic friction by retiring outdated tools or processes. For example, replacing blame-centric forms with learning logs can transform near-miss reporting into an opportunity for growth rather than criticism. Second, aesthetic standards should be embedded into system design by adopting criteria such as efficacy, robustness, scalability, and maintainability. Training QA teams as system gardeners who can further enhance this approach. Finally, cross-pollination between departments can foster innovation; for instance, involving designers in QA processes can lead to more visually engaging outcomes.

By embedding elegance into their quality systems alongside efficiency and effectiveness, organizations can move from mere survival to thriving excellence. Compliance becomes an intuitive outcome of well-designed processes rather than a burdensome obligation. Innovation flourishes in frictionless environments where tools invite improvement rather than resistance. Organizations ready to embrace this transformative approach should begin by conducting an “Elegance Audit” of their most cumbersome processes to identify opportunities for improvement. Through these efforts, excellence becomes not just a goal but a natural state of being for the entire system.

Quality Systems as Living Organizations: A Framework for Adaptive Excellence

The allure of shiny new tools in quality management is undeniable. Like magpies drawn to glittering objects, professionals often collect methodologies and technologies without a cohesive strategy. This “magpie syndrome” creates fragmented systems—FMEA here, 5S there, Six Sigma sprinkled in—that resemble disjointed toolkits rather than coherent ecosystems. The result? Confusion, wasted resources, and quality systems that look robust on paper but crumble under scrutiny. The antidote lies in reimagining quality systems not as static machines but as living organizations that evolve, adapt, and thrive.

The Shift from Machine Logic to Organic Design

Traditional quality systems mirror 20th-century industrial thinking: rigid hierarchies, linear processes, and documents that gather dust. These systems treat organizations as predictable machines, relying on policies to command and procedures to control. Yet living systems—forests, coral reefs, cities—operate differently. They self-organize around shared purpose, adapt through feedback, and balance structure with spontaneity. Deming foresaw this shift. His System of Profound Knowledge—emphasizing psychology, variation, and systems thinking—aligns with principles of living systems: coherence without control, stability with flexibility.

At the heart of this transformation is the recognition that quality emerges not from compliance checklists but from the invisible architecture of relationships, values, and purpose. Consider how a forest ecosystem thrives: trees communicate through fungal networks, species coexist through symbiotic relationships, and resilience comes from diversity, not uniformity. Similarly, effective quality systems depend on interconnected elements working in harmony, guided by a shared “DNA” of purpose.

The Four Pillars of Living Quality Systems

Purpose as Genetic Code
Every living system has inherent telos—an aim that guides adaptation. For quality systems, this translates to policies that act as genetic non-negotiables. For pharmaceuticals and medical devices this is “patient safety above all.”. This “DNA” allowed teams to innovate while maintaining adherence to core requirements, much like genes express differently across environments without compromising core traits.
Self-Organization Through Frameworks
Complex systems achieve order through frameworks as guiding principles. Coherence emerges from shared intent. Deming’s PDSA cycles and emphasis on psychological safety create similar conditions for self-organization.
Documentation as a Nervous System
The enhanced document pyramid—policies, programs, procedures, work instructions, records—acts as an organizational nervous system. Adding a “program” level between policies and procedures bridges the gap between intent and action and can transform static documents into dynamic feedback loops.
Maturity as Evolution
Living systems evolve through natural selection. Maturity models serve as evolutionary markers:
- Ad-hoc (Primordial): Tools collected like random mutations.
- Managed (Organized): Basic processes stabilize.
- Standardized (Complex): Methodologies cohere.
- Predictable (Adaptive): Issues are anticipated.
- Optimizing (Evolutionary): Improvement fuels innovation.

Cultivating Organizational Ecosystems: Eight Principles

Living quality systems thrive when guided by eight principles:

Balance: Serving patients, employees, and regulators equally.
Congruence: Aligning tools with culture.
Human-Centered: Designing for joy—automating drudgery, amplifying creativity.
Learning: Treating deviations as data, not failures.
Sustainability: Planning for decade-long impacts, not quarterly audits.
Elegance: Simplifying until it hurts, then relaxing slightly.
Coordination: Cross-pollinating across the organization
Convenience: Making compliance easier than non-compliance.

These principles operationalize Deming’s wisdom. Driving out fear (Point 8) fosters psychological safety, while breaking down barriers (Point 9) enables cross-functional symbiosis.

The Quality Professional’s New Role: Gardener, Not Auditor

Quality professionals must embrace a transformative shift in their roles. Instead of functioning as traditional enforcers or document controllers, we are now called to act as stewards of living systems. This evolution requires a mindset change from one of rigid oversight to one of nurturing growth and adaptability. The modern quality professional takes on new identities such as coach, data ecologist, and systems immunologist—roles that emphasize collaboration, learning, and resilience.

To thrive in this new capacity, practical steps must be taken. First, it is essential to prune toxic practices by eliminating fear-driven reporting mechanisms and redundant tools that stifle innovation and transparency. Quality professionals should focus on fostering trust and streamlining processes to create healthier organizational ecosystems. Next, they must plant feedback loops by embedding continuous learning into daily workflows. For instance, incorporating post-meeting retrospectives can help teams reflect on successes and challenges, ensuring ongoing improvement. Lastly, cross-pollination is key to cultivating diverse perspectives and skills. Rotating staff between quality assurance, operations, and research and development encourages knowledge sharing and breaks down silos, ultimately leading to more integrated and innovative solutions.

By adopting this gardener-like approach, quality professionals can nurture the growth of resilient systems that are better equipped to adapt to change and complexity. This shift not only enhances organizational performance but also fosters a culture of continuous improvement and collaboration.

Thriving, Not Just Surviving

Quality systems that mimic life—not machinery—turn crises into growth opportunities. As Deming noted, “Learning is not compulsory… neither is survival.” By embracing living system principles, we create environments where survival is the floor, and excellence is the emergent reward.

Start small: Audit one process using living system criteria. Replace one control mechanism with a self-organizing principle. Share learnings across your organizational “species.” The future of quality isn’t in thicker binders—it’s in cultivating systems that breathe, adapt, and evolve.

Principles behind a good system

System Thinking requires operating in a paradigm where we see our people, organizations, processes and technology as part of the world, a set of dynamic entities that display continually emerging patterns arising from the interactions among many interdependent connecting components.

Principle	Description
Balance	The system creates value for the multiple stakeholders. While the ideal is to develop a design that maximizes the value for all the key stakeholders, the designer often has to compromise and balance the needs of the various stakeholders.
Congruence	The degree to which the system components are aligned and consistent with each other and the other organizational systems, culture, plans, processes, information, resource decisions, and actions.
Convenience	The system is designed to be as convenient as possible for the participants to implement (a.k.a. user friendly). System includes specific processes, procedures, and controls only when necessary.
Coordination	System components are interconnected and harmonized with the other (internal and external) components, systems, plans, processes, information, and resource decisions toward common action or effort. This is beyond congruence and is achieved when the individual components of a system operate as a fully interconnected unit.
Elegance	Complexity vs. benefit — the system includes only enough complexity as is necessary to meet the stakeholder’s needs. In other words, keep the design as simple as possible and no more while delivering the desired benefits. It often requires looking at the system in new ways.
Human	Participants in the system are able to find joy, purpose and meaning in their work.
Learning	Knowledge management, with opportunities for reflection and learning (learning loops), is designed into the system. Reflection and learning are built into the system at key points to encourage single- and double-loop learning from experience to improve future implementation and to systematically evaluate the design of the system itself.
Sustainability	The system effectively meets the near- and long-term needs of the current stakeholders without compromising the ability of future generations of stakeholders to meet their own needs.

Pillars of Good System Design

Root Cause Analysis Deficiencies

An appropriate level of root cause analysis should be applied during the investigation of deviations, suspected product defects and other problems. This can be determined using Quality Risk Management principles. In cases where the true root cause(s) of the issue cannot be determined, consideration should be given to identifying the most likely root cause(s) and to addressing those. Where human error is suspected or identified as the cause, this should be justified having taken care to ensure that process, procedural or system based errors or problems have not been overlooked, if present.
Appropriate corrective actions and/or preventative actions (CAPAs) should be identified and taken in response to investigations. The effectiveness of such actions should be monitored and assessed, in line with Quality Risk Management principles.
EU Guidelines for Good Manufacturing Practice for Medicinal Products for Human and Veterinary Use, Chapter 1 Pharmaceutical System C1.4(xiv)

The MHRA cited 210 companies in 2019 on failure to conduct good root cause analysis and develop appropriate CAPAs. 6 of those were critical and a 100 were major.

My guess is if I asked those 210 companies in 2018 how their root cause analysis and CAPAs were doing, 85% would say “great!” We tend to overestimate our capabilities on the fundamentals (which root cause analysis and CAPA are) and not to continuously invest in improvement.

Of course, without good benchmarking, its really easy to say good enough and not be. There can be a tendency to say “Well we’ve never had a problem here, so we’re good.” Where in reality its just the problem has never been seen in an inspection or has never gone critical.

The FDA has fairly similar observations around root cause analysis. As does anyone who shares their metrics in any way. Bad root cause and bad CAPAs are pretty widespread.

This comes up a lot because the quality of CAPAs (and quantity) are considered key indicators of an organization’s health. CAPAs demonstrate that issues are acknowledged, tracked and remediated in an effective manner to eliminate or reduce the risk of a recurrence. The timeliness and robustness of these processes and records indicate whether an organization demonstrates effective planning and has sufficient resources to manage, resolve and correct past issues and prevent future issues.

A good CAPA system covers problem identification (which can be, and usually is a few different processes), root cause analysis, corrective and preventive actions, CAPA effectiveness, metrics, and governance. It is a house of cards, short one and the whole structure will fall down around you, often when you least need it to.

We can’t freeze our systems with superglue. If we are not continually improving then we are going backwards. No steady state when it comes to quality.