How to Create a Corrective Action Plan (CAP) for Government Contractors
So, your organization received a Corrective Action Request (or CAR for short) and it’s your job to address it. But navigating the months-long, multi-step process to resolve a CAR can be overwhelming.
It’s even more overwhelming if you’ve never been through this process before. Maybe your organization has maintained a strong record until now (if so, congrats!). Or maybe you’re new to this whole “government property management” thing and trying to read all the manuals and procedures is giving you a major case of computer vision.
In the past, we’ve talked about how to respond to CARs. Today, we’re going to go in-depth on one part of this process: developing a Corrective Action Plan (CAP). In this post we’ll show you exactly how to create a Corrective Action Plan. These steps are based directly on DCMA procedures and expert recommendations.
Let’s get started.
What is a CAP?
Seasoned government property managers likely know what a Corrective Action Plan, or CAP, is. But for the rookies and those who want a refresher, we’ll define it.
The DCMA defines a Corrective Action Plan as “the detailed plan identifying management controls, tactics, techniques, procedures, training, resources, and working environment changes likely to preclude future non-compliance.”
In other words: A Corrective Action Plan is a plan identifying how to prevent non-compliance. It is based on the findings that led to a Corrective Action Request (CAR). A government contractor who has received a CAR of a certain level is required to develop and execute a CAP.
Why Do I Need to Submit a CAP?
Government Contractors need to submit a Corrective Action Plan when they receive a Corrective Action Request of Level II or higher.
CAPs are part of the CAR process because, according to Section 1(h) of DCMA Manual 933-01, “The CAP will include all corrective actions, management controls, and actions deemed necessary to prevent the finding from reoccurring.”
Essentially, a CAP shows that you know what caused the finding, and that you’re taking actions to correct the non-compliance and avoid making the same mistakes in the future. By submitting a thorough CAP, you can reassure the auditors (and your customer) that your organization is indeed responsible and can be trusted with valuable government property.
After your organization receives a Corrective Action Request, the DCMA Inspector General – Inspections and Evaluations Team (IG-I&E) will email a CAP Tasking Memorandum to you. Once they do this, the clock starts ticking! From that moment on, you have 275 calendar days to complete the CAP Milestone Timeline.
See the picture below for the full CAP Milestone Timeline:
While the CAP Milestones may look intimidating, the basic CAP procedure is surprisingly simple. To reach your CAP Milestones:
- Perform Root Cause Analysis (RCA) for each Level II finding to determine the cause of non-compliance
- Create a brief summary of the RCA for each finding
- Submit the RCA
- Develop your CAP based on the RCA
- Submit the CAP
- Receive approval of your CAP
- Implement all parts of the CAP within 150 days after CAP approval
The detailed CAP procedure, from DCMA Manual 933-01, is rewritten here for your convenience:
- The CAP Milestone Timeline begins upon receipt of CAP Tasking notification.
- For each Level II finding documented in the Agency CAP Tracking tool, perform Root Cause Analysis (RCA) based on Continuous Process Improvement (CPI) Lean Six Sigma (LSS) methodology (solicit assistance from a LSS Green/Black Belt if necessary).
- Coordinate RCA with the Region/HQ Component Point of Contact (POC) or designated support equivalent. The RCA will be presented to the cognizant Region/HQ Component no later than 30 calendar days after receipt of the CAP Tasking Memorandum. An effective RCA will identify the basic cause that, when corrected, will prevent reoccurrence of the finding.
- Annotate a brief summary of the RCA in the RCA column in the Agency CAP Tracking tool or attach the RCA document(s) to the list item.
- Enter the RCA completion date in the RCA completion date column of the Agency CAP Tracking tool and inform the cognizant Region/HQ Component POC that the RCA has been submitted.
- Each Level II finding documented in the Agency CAP Tracking tool requires the development and implementation of a CAP. The CAP is due 30 calendar days after the RCA acceptance date. The CAP will be developed in coordination with the Region/HQ Component CAP POC and will contain the detailed plans to correct and prevent the finding based on the RCA accepted by the Region/HQ Component.
- The CAP will identify the management controls, elements, or processes that when implemented will prevent the root cause from reoccurring. Annotate the CAP in the Level II CMO CAP column in the Agency CAP Tracking tool or attach the CAP document(s) to the list item.
- All CAPs require approval of the reviewed organization Commander/Director prior to submission to the Region/HQ Component.
- Enter the CAP completion date in the CAP completion date column of the Agency CAP Tracking tool, check the CMO Commander/Director CAP Approved block, and inform the cognizant Region/HQ Component POC that the CAP has been submitted.
- All CAP management controls, elements, or processes must be fully implemented no later than 150 calendar days after the Region/HQ Component accepts the CAP.
The CAP procedure differs slightly with Level III and Level IV findings. Be sure to double-check the DCMA Manual 933-01 if you received a Level III or IV CAR.
For the visual learners among us, there is a flowchart that illustrates the Corrective Action process:
Developing a CAP
After you perform Root Cause Analysis and it has been approved, it’s time to develop the Corrective Action Plan. It should include:
- The root cause of non-compliance
- Action(s) taken or planned to correct the non-compliance
- Timeline of action(s)
- Person responsible for the action(s)
- Determination of whether other processes or products were affected
Let’s explore these in-depth.
Your CAP starts with the results of your RCA. Briefly explain what specific factor caused the issue, and how it led to non-compliance.
Your CAP will also include all actions that need to be performed in order to correct the non-compliance. It’s recommended that any solutions and action you take should create long-term change, or ideally, permanently fix the non-compliance. Putting a band-aid on it will likely only cause larger issues later.
Be sure to include a timeline of actions and who will oversee each action. Not only is this required, but it will make it easier for your organization to implement your CAP.
In addition, you’re required to research and determine whether processes or products/services other than those specific to the non-compliance were affected by the root cause. This may include products already delivered to the customer.
Once you’ve compiled this, you can submit your newly created CAP in the Agency CAP tracking tool. Be sure to notify the Region/HQ Component POC that you’ve submitted the CAP to get the review process kick-started.
Now that your CAP has been accepted, it’s time to implement it!
Every CAP varies drastically between contractors (or even between CAPs developed by the same contractor!) so we won’t be able to walk you through implementing your own specific CAP here. However, for extra help implementing your CAP, you can talk to one of our asset management experts. Feel free to fill out a contact form here or call at 443-708-4215 to get in touch!