Management System Certification
Audit Summary Report
Organization:
Universitas Negeri Semarang
Address:
Gedung H Kampus Sekaran, Gunungpati Semarang Jawa Tengah
Standard(s):
ISO 9001:2008 & IWA 2:2007
Representative:
Mr. Drs. Heri Yanto MBA., PhD
Site(s) audited:
Address as above
Date(s) of audit(s):
EAC Code:
37
80.3
Effective No.of
Personnel:
+ 1770
No. of Shifts:
Normal shift
Lead auditor:
Widiyanto
Additional team
member(s):
Yuni Kharisman
Additional
Attendees and
Roles
-
NACE Code:
Accreditation Body(s): UKAS
17-19 February 2014
Technical Area
code:
QM37.2
This report is confidential and distribution is limited to the audit team, audit attendees client representative
and the SGS office.
1. Audit objectives
The objectives of this audit were:
to confirm that the management system conforms with all the requirements of the audit standard;
to confirm that the organization has effectively implemented the planned management system;
to confirm that the management system is capable of achieving the organization’s policy objectives.
2. Scope of certification
"Design curriculum and material lecture, education from undergraduate program
(Education Sciences Faculty, Languages and Arts Faculty, Social Sciences Faculty,
Mathematics and Natural Sciences Faculty, Engineering Faculty, Sport Sciences Faculty,
Economics Faculty and Law Faculty) and Supporting functions”
Has this scope been amended as a result of this audit?
Yes
No
This is a multi-site audit and an Appendix listing all relevant sites and/or remote
locations has been established (attached) and agreed with the client
Yes
No
3. Current audit findings and conclusions
The audit team conducted a process-based audit focusing on significant aspects/risks/objectives required
by the standard(s). The audit methods used were interviews, observation of activities and review of
documentation and records.
The structure of the audit was in accordance with the audit plan and audit planning matrix included as
annexes to this summary report.
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The audit team concludes that the organization
has
has not established and maintained its
management system in line with the requirements of the standard and demonstrated the ability of the
system to systematically achieve agreed requirements for products or services within the scope and the
organization’s policy and objectives.
Number of nonconformities identified:
0
Major
6
Minor
Therefore the audit team recommends that, based on the results of this audit and the system’s
demonstrated state of development and maturity, management system certification be:
Granted /
Continued /
Withheld /
Suspended until satisfactory corrective action is completed.
4. Previous Audit Results
The results of the last audit of this system have been reviewed, in particular to assure appropriate correction
and corrective action has been implemented to address any nonconformity identified. This review has
concluded that:
Any nonconformity identified during previous audits has been corrected and the corrective action
continues to be effective. (Refer to Section 6 for details)
The management system has not adequately addressed nonconformity identified during previous audit
activities and the specific issue has been re-defined in the nonconformity section of this report.
5. Audit Findings
The audit team conducted a process-based audit focusing on significant aspects/risks/objectives. The audit
methods used were interviews, observation of activities and review of documentation and records.
The management system documentation demonstrated conformity with the requirements
of the audit standard and provided sufficient structure to support implementation and
maintenance of the management system.
The organization has demonstrated effective implementation and maintenance /
improvement of its management system and is capable of achieving its policy objectives.
Yes
No
Yes
No
The organization has demonstrated the establishment and tracking of appropriate key
performance objectives and targets and monitored progress towards their achievement.
Yes
No
The internal audit program has been fully implemented and demonstrates effectiveness
as a tool for maintaining and improving the management system.
Yes
No
The management review process demonstrated capability to ensure the continuing
suitability, adequacy and effectiveness of the management system.
Yes
No
Throughout the audit process, the management system demonstrated overall
conformance with the requirements of the audit standard.
Yes
No
Yes
No
Certification claims are accurate and in accordance with SGS guidance and the
organization is effectively controlling the use of certification documents and
marks.
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6. Nonconformities
NonConformity
N° 1 of 6
Area / Department /
Process:
Document Ref.:
Issue/Rev. Status:
Major
Minor
Management Representative, Prodi Pendidikan Teknik Elektro, Pendidikan Teknik
Bangunan, Pendidikan Matematika,
Prosedur mutu Penyusunan
Standard Ref.:
Clause 5.5.3
Satuan Acara Perkuliahan
(No. Dok. PM-akD-06 Rev. 01
tanggal terbit 1 September
2012)
01
CAR Close out date:
Next Visit
Details of Non-Conformity:
Found during audit that internal communication to ensure the effectiveness of quality management system
is always implemented effectively.
1. Found recurrence in many programs/prodi regarding the previous nonconformities:
a. Formulir Ujian (Form-02-AKD-19 Rev. 01 tanggal terbit 1 September 2013) matakuliah Kalkulus
SKS 3 Semester Gasal/2013-2014 Prodi Pendidikan Teknik Elektro date 8 January 2014, was
not validated
b. Kontrak Perkuliahan Mata Kuliah Praktik Pengukuran Besaran Listrik Program Studi Teknik
Elektro/Pendidikan Teknik Elektro, Semester Gasal 2013-2014, not validated
c. Kontrak Perkuliahan mata Kuliah Menggambar Konstruksi Bangunan Nomor Kode MK/SKS:
E1014302/2 Jurusan/Program Studi Teknik Sipil/S1 PTB Semester III was not validated by
student and lecturers.
d. Soal Ujian Semester Ganjil Tahun Ajaran 2013/2014 Fakultas Teknik Nama mata Kuliah
Menggambar Konstruksi Bangunan SKS 2 SKS Semester Ganjil 2014. Waktu Ujian 120. Not
validation in field “Review Kajur/Kaprodi”
e. Formulir Soal Ujian Akhir Semester Ganjil Tahun Ajaran 2013/2014 Matakuliah Matematika
Diskrit.
f. Formulir soal ujian Ujian Akhir Semester is used for Ujian Tengah Semester at prodi KTP.
2. System does not ensure the previous SGS audit report is effectively distributed to all
programs/prodis to avoid the recurrence, e.g: found during audit that several prodi did not received
and get complete information regarding the previous SGS audit report which cause the above
recurrences.
3. Found different implementations regarding the interpretation of validation for SAP, Syllabus,
Kontrak and Bahan Ajar when upload process to SIKADU is applied.
Several programs still maintain the validation evidences since the system not yet accommodate the
validation function and there is no regulation defined that Prosedur mutu Penyusunan Satuan Acara
Perkuliahan (No. Dok. PM-akD-06 Rev. 01 tanggal terbit 1 September 2012) is no longer be used.
However several programs no longer maintain the validation.
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NonConformity
N° 2 of 6
Area / Department /
Process:
Document Ref.:
Issue/Rev. Status:
Major
Minor
Prodi Pendidikan Teknik Bangunan, Prodi managament
Kontrak Perkuliahan
0
Standard Ref.:
CAR Close out date:
Clause 7.1
Next Visit
Details of Non-Conformity:
Planning of product/service realization is not always implemented consistenty:
1. Kontrak Perkuliahan Mata Kuliah Menggambar: Menggambar Konstruksi Bangunan, No Kode
MK/SKS E1014302/2, Semester III, 3. Pembobotan Nilai not completely defined for a. Bobot Nilai
Harian (NH) = A (diisi bilangan); Bobot Nilai Ujian Tengah Semester (UTS) = B (diisi bilangan);
Bobot Nilai Ujian AKhir Semester (UAS) = C (diisi bilangan), Nilai Akhir = (A NH+ B UTS + C
UAS)/A+B+C.
2. Presentase Penilaian in Kontrak Perkuliahan Matakuliah Etika Bisnis 1. Pop Quiz 10%, UTS 15%,
Tugas Paper (Presentasi) 25%, UAS 50% in SAP Mata kuliah Etika Bisnis Pertemuan Ke 1 Materi
Kontrak Perkuliahan, Kontrak Perkuliahan Matakuliah Etika Bisnis Pertemuan ke 1 Persentase
Penilaian 1. Pop Kuis 10%, Mid 25%, Tugas Paper 30%, UAS 35%
NonConformity
N° 3 of 6
Area / Department /
Process:
Document Ref.:
Issue/Rev. Status:
Major
Minor
Library
Laporan Kerusakan
0
Standard Ref.:
CAR Close out date:
Clause 6.3
Next Visit
Details of Non-Conformity:
Lack of evidences that the facilities are always under controlled conditions to ensure they functioned
normally, e.g: found only 2 fans out of 6 fans are normally function in the “ruang terbitan berkala”.
No Fire Prevention Plan in library as auditor note no fire estinguisher placed during site visit
NonConformity
N° 4 of 6
Area / Department /
Process:
Document Ref.:
Issue/Rev. Status:
Major
Minor
Management Representative
PM-BPM-09
0
Standard Ref.:
CAR Close out date:
Clause 5.6.2
Next Visit
Details of Non-Conformity:
Due to the previous non conformity no 6 of 9 can not adequately closed out and the nonconformity is
redefine as minor noncorformity.
Previous non-conformity
In-adequate evidence that all agenda of Management Review has been discussed during last management
review dated 31 January 2013, such as:
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a.
b.
c.
d.
Customer Complaint
Status of Preventive and Corrective Actions.
Follow Up Actions from Previous Management Review.
Recommendation for Improvement
NonConformity
N° 5 of 6
Major
Minor
Area / Department /
Process:
Document Ref.:
Evaluation Lecturer (Contract)
QM
Standard Ref.:
Issue/Rev. Status:
0
CAR Close out date:
Standard Ref.: Clause 4.1 ;
clause 4.2.3
Next Visit
Details of Non-Conformity:
Details of Non-Conformity:
Lack of evidence that evaluation performance of contract lecturer is effectively performed as required as we
found evidence that evaluation was not stipulated in the procedures. i.e.: evaluation contract lecturer at FIS,
Geography, PPKN, and Pendidikan Bahasa Inggris.
Moreover the records check list evaluation i.e.: micro teaching and sit in witnesses (pedagogic) was found
not registered and controlled within the quality management system.
NonConformity
N° 6 of 6
Major
Minor
Area / Department /
Process:
Document Ref.:
Library prodi Bahasa inggris , FIP – (KTP)
QM
Standard Ref.:
Issue/Rev. Status:
0
CAR Close out date:
Standard Ref.: Clause
7.5.1
Next Visit
Details of Non-Conformity:
Details of Non-Conformity:
System does not always ensure that the process service provision is carried out under controlled condition,
as we found evidence as follow:
- No evidence that procedures in perpustakaan (library) Jurusan is establish. i.e.: Maintenance
procedures, inventory control, library management (registered new book, membership, lend process
etc.).
- No evidence that maintenance procedure of laboratory equipment is establish. i.e.: Maintenance
program, maintenance procedures etc.
Client Proposed Action to Address Minor Non-Conformances Raised at this Audit:
•
Nonconformities detailed here shall be addressed through the organization’s corrective action process, in
accordance with the relevant corrective action requirements of the audit standard and shall include actions to
analyse the cause of the nonconformity and prevent recurrence, and complete records maintained.
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Corrective actions to address identified major nonconformities shall be carried out immediately including
a cause anlaysis, and SGS notified of the actions taken within 30 days. An SGS auditor will perform a
follow up visit within 90 days to confirm the actions taken, evaluate their effectiveness, and determine
whether certification can be granted or continued.
Corrective actions to address identified major nonconformities shall be carried out immediately including
a cause anlaysis, and records with supporting evidence sent to the SGS auditor for close-out within
90 days.
Corrective Actions to address identified minor non conformities including a cause anlaysis, shall be
documented on a action plan and sent by the client to the auditor within 90 days for review. If the actions
are deemed to be satisfactory they will be followed up at the next scheduled visit.
Corrective Actions to address identified minor non-conformities including a cause anlaysis,have
been detailed on an action plan and the intended action reviewed by the Auditor, deemed to be
satisfactory and will be followed up at the next scheduled visit.
Appropriate cause analysis and immediate corrective and preventative action taken in response to
each non-conformance as required.
Note:- Initial, Re-certification and Extension audits – recommendation for certification cannot be made unless check box 4 is completed. For
re-certification audits the time scales indicated may need to be reduced in order to ensure re-certification prior to expiry of current
certification.
Note: At the next scheduled audit visit, the SGS audit team will follow up on all identified nonconformities to confirm the effectiveness of the
corrective actions taken.
7. General Observations & Opportunities for Improvement
Management Representative
1. Recommendation to update the Prosedur mutu Penyusunan Satuan Acara Perkuliahan (No. Dok. PMakD-06 Rev. 01 tanggal terbit 1 September 2012) with the current process.
2. Recommendation to define the validation method for learning contract/kontrak perkuliahan
Pendidikan teknik Elektro
3. Recommendation to develop and record the working paper which demonstrate the quality objective
measurement results.
FMIPA-Prodi Biology
4. Consideration should be given to standardized the form of Lembar verifikasi Silabus/Satuan Acara
perkuliahan by give number.
5. Care should be taken to ensure the monthly monitoring is completed example Jurnal Perkuliahan
Semester Gasal Tahun 2013/2014 nama Mata kuliah Fisiologi Tumbuhan 3 SKS and Matakuliah Biologi
molekuler (2 SKS)
FE – Prodi Akuntansi
6. Consideration should be given to ensure the to calculation of quality objective are documented.
Library
7. Recommendation to develop the documented procedures regarding all related aspects of library
operations.
Fakultas Ilmu Keolahragaan (Prodi IKOR & Prodi PJKR)
8. Recommendation to perform satisfaction index of mitra kerja / stake holder after PKL is done. This to
review the performanceof student.
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Fakultas Ilmu Sosial (Prodi Geography & Prodi PPKN)
9. Care should be taken to improve the analysis data of open feedback from student resulted IKDP, as we
noted that some feedback may contain complain, compliment, suggestions, its recommend to improve
the analysis by categorize the feedback and monitored the trends.
10. Strongly recommend to review the maximum capacity (limitation) of new class, this to ensure that
learning process effectiveness. During audit we noted that some class is containing up to 68 students
and the subjects was delivered by new contract lecturer.
11. Although KKL is currently freeze, Strongly recommend to ensure that evaluation resulted KKL is
established and performed as we noted and observed that evaluation of KKL was not established and
performed.
Fakultas Bahasa dan Seni / FBS (Prodi Pendidikan Bahasa Inggris & Prodi Pendidikan Bahasa Perancis)
12. Care should be taken to ensure that quality objectives measured is applied with SMART format.
13. Strongly recommend to ensure that safety aspect in workshop ceramics is equipped with fire
extinguisher, as we noted that there is burner / oven burners is operated in the studio and the fire
extinguisher was not observed in place.
Fakultas FIP / Fakultas Ilmu Pendidikan (KTP & KLS)
14. Care should be taken to ensure that control monitoring of replace day of learning process is established
and performed and it is recommended is counted as the lecturer performance indicators.
15. Strongly recommend to ensure that monitoring achievement of quality objectives measured is accurate
this to ensure that evaluation quality objectives performance is not misleading.
o
8. Opening and Closing Meeting Attendance Record
Name
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