This procedure describes the steps to be taken when a nonconformity is found within the Information Security Management System (ISMS). A nonconformity is defined by ISO as the “non-fulfillment of a requirement”.
This is a wide definition which basically means that the ISMS is not succeeding in its purpose, which is to fulfil the information security requirements of the organization. A nonconformity may arise for many reasons, in many forms and from many different sources. The purpose of this procedure is to ensure that they are recorded when they are identified and that the appropriate steps are taken to ensure that the immediate and wider actual and potential impacts of the nonconformity are addressed.
In addition to internal and external audits, non conformity may be identified from the day- to-day performance of procedures, management meetings and communication with suppliers, customers and other interested parties.
2 Nonconformity Management Procedure
2.1 Procedure Diagram
The procedure for identifying and managing non conformity is summarized in the diagram below. The detail of the steps is described in the following sections.
2.2 Identifying Nonconformities
Nonconformities may be identified from any source and the [Information Security Manager] will encourage staff, users, customers and suppliers to propose ways in which they can be addressed. Such nonconformities may be identified from:
- Security reviews
- Team meetings
- Supplier meetings
- Risk assessments
- User surveys
- Internal and external audits
However, the above is not an exhaustive list.
2.3 Add to Nonconformity and Corrective Action Log
Once identified, the nonconformity will be documented within the Nonconformity and Corrective Action Log with a status of “Open”. At this stage, the action to correct the nonconformity has not necessarily been determined. As much detail as possible should be specified as to the exact nature of the nonconformity.
2.4 React to the Nonconformity
If action needs to be taken to address the nonconformity immediately then this should be done without delay. This may be to fix it, stop it from getting worse or to reduce its effects until further action may be taken. Appropriate resources should be allocated to addressing the nonconformity depending on the current assessment of its seriousness. Actions taken should be recorded in the action log, with dates.
2.5 Cause determination
Once logged and initial reactive actions put in place, the nonconformity will be evaluated to assess its underlying cause i.e. why it has arisen. Other parties may be consulted during this stage to understand the mechanism and events leading to the nonconformity. The identified cause should be recorded in the action log with as much description as appropriate.
2.6 Assess potential impact
Once the cause is understood, a review should be undertaken to assess whether similar nonconformities already exist elsewhere within the ISMS and whether they could potentially arise in the future. The findings of this review should be recorded in the action log.
2.7 Implement corrective action
Once the cause and real or potential impact has been established, appropriate corrective action should be identified to address both the current situation and potential future impact of the nonconformity. The expected benefits of correcting the nonconformity should be sufficient to justify the resources required to achieve the corrective action. The details of the corrective action to be taken should be recorded in the action log, along with the timescale and person responsible. Dated progress updates should also be added when appropriate. Once corrective action has been completed the status of the nonconformity record within the Nonconformity and Corrective Action Log should be updated to “Review Pending” and the date of closure recorded.
2.8 Review effectiveness of corrective action
After a reasonable period of time (which will depend on the nature of the nonconformity and the corrective action) the effectiveness of the corrective action should be reviewed to assess whether it has fixed the issue, including its actual and potential impacts. If the benefits expected are not achieved, the reasons for this will be investigated as part of the regular management review meeting. If successful, the date and results of the review will be recorded, and the status of the nonconformity will be updated to “Closed”.
2.9 Amend ISMS if necessary
If the nonconformity is judged to have occurred due to a fault in the ISMS, it may be necessary to amend the ISMS itself, including any relevant policies, procedures and forms. This should be done with the agreement of top management.