1st Surveillance ISO 9001 Report For UB

1st Surveillance
Report for:
Universitas Brawijaya
LRQA reference: JKT 6003728/ 0008

Assessment dates: 9-11 May 2012
Assessment location: Jl. Veteran Malang - Malang, Jawa Timur
Assessment criteria: ISO 9001:2008
Assessment team: Rusli Ananda (ID: 04946)
Anton Nurkholis
Sugeng Hartono
Dede Gunawan
LRQA office: Surabaya
Contents
1. Executive report ........................................................................................................ 3

2. Assessment summary ............................................................................................... 4
3. Assessment Findings Log - ISO 9001:2008 ............................................................ 21
4. - SUB REPORT ISO 9001:2008 .............................................................................. 25
5. Assessment Findings Log - SUB REPORT ISO 9001:2008 .................................... 33
10. Assessment schedule ............................................................................................. 38
11. Continual improvement tracking log ([ISO9001:2008], [Malang]) ........................... 39
12. Visit theme selection ............................................................................................... 40
Attachments
This report was presented to and accepted by:
Name: Mr. Prof. Dr. Ir. Yogi Sugito

Job title: Rector of UB
Lloyd's Register Quality Assurance Limited, its affiliates and subsidiaries and their respective officers, emp loyees or agents are,
individually and collectively, referred to in this clause as "LRQA". LRQA assumes no responsibility and shall not be liable to any person
for any loss, damage or expense caused by reliance on the information or advice in this document or howsoever provided, unless that
person has signed a contract with the relevant LRQA entity for the provision of this information or advice and in that case any
responsibility or liability is exclusively on the terms and conditions set out in that contract.
Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 2 of 40

1. Executive report
Assessment outcome:
st
1 surveillance visit was done to verify consistency and effectiveness of quality management system
implementation that refer to ISO 9001:2008.
This assessment was conducted by Rusli Ananda as TL and accompanied by several members (Mr.
Dede Gunawan, Mr. Sugeng Hartono and Mr. Anton Nurkholis).
Approach of assessment was biz process compliance; there was no specific themes defined since
management of university still want to ensure that awareness of quality management system has been
comprehended in a whole faculty and dept.
Typical discrepancy still observed; these were related to activity such as management review and internal
audit. Other aspect of teaching learning related to quality system was improved; this was also found at
supporting activities of organization.
Though a lot of discrepancy noted with grading NC minor (5 open status, 11 new notes), no major NC
issued in this visit. Regarding to this result, therefore, organization was recommended to maintain
certification of ISO 9001:2008 and subjected to surveillance visit.
Next visit will take 12 man days with specific area planned prior to visit conducted.
System effectiveness and continual improvement:
Several system benefits and improvements have been highlighted by organisation in terms of quality
system documentation and system implementation in helping all personnel in performing their tasks.
Awareness of people in running quality system based on ISO 9001:2008 requirement well improved
comparing to previous visit.
Areas for management attention:
Similar nonconformities were observed, particularly issues that related to internal audit,
management review, quality objectives and other basic requirement of ISO 9001:2008
standard.
On next visit, these NC shall be effectively eliminated; otherwise, it potentially impact to
certification status.
Awareness of ISO 9001:2008 requirement shall be improved to minimize recurrence
problem.

2. Assessment summary
Introduction:
The surveillance assessment was conducted on 9-11 May 2012 with selected area defined in assessment
plan.
Method of assessment was explained during opening meeting and understood by audiences.
Detail of finding as reported on the following process table and audit finding log.
Closing meeting was held in organization premises and attended by relevant auditee and managements
organization.
Assessor: Rusli Ananda (Assessor-ID:04946),
Assessment of: Top Management interview Auditee(s): Mr. Prof Yogi Sugito (Rector)
Mr. Warkoem (2nd Deputy
Rector).
Mr. Prof. M. Bisri (PJM)
Audit trails and sources of evidence:
Strategic planning of Universitas Brawijaya (RENSTRA 2006 2011 and continued to RENSTRA 2011-
2015).
Management review and internal audit (reviewed at each area of assessment)
Corrective action status (reviewed at each area of audit)
Customer complaint (status can be accessed at each faculty over online application)
Use of Logo
Evaluation and conclusions:
Top Management Interview.
Management interview was done to know overall strategic planning of UB to achieve their vision which
was stated as World Class Entrepreneurial University.
It was explained by Prof Yogi Sugito (Rector of UB) that all planned arrangement of UB to achieve their
vision was already documented at RENSTRA 2006 2011 and continued to RENSTRA 2011-2015.
It was also presented design of quality management system by Mr. M. Bisri (Head of PJM UB) that was
used to manage overall process of teaching learning, research and community development at UB.
In general, it can be concluded as following.
Vision and mission organization has been explained; commitment of Management to implement
management system was demonstrated.
Organization has changed; several bureaus was established to support strategy of university in
achieving the target.
Planning and objective was available. Relevant documented procedure was maintained.
Open mind and cooperative during assessment
Quality awareness improved from previous visit.
Competent people who deliver teaching learning process.
Follow up of previous NC finding was good.
Some outstanding achievement was informed such as service excellent, financial report that
awarded as WTP (Wajar Tanpa Pengecualian) and as the fastest organization that prepare follow
up action.
Improvement Notes
Strategic Planning of university has been documented on RENSTRA 2011-2015; regular
evaluation on achievement of this planning has not been done. It was explained that evaluation
will be done, data compilation still on progress.

Assessment of: Fakultas Peternakan Auditee(s): Mr. Kusmartono and team.
Fakultas PKH Ms. Aulanniam / Ms. Masdiana /
Ms. Sri Murwani and team

Renstra fakultas Peternakan / Business process mapping / Audit report / Pedoman akademik
Review Implementation of Quality Manual, Procedure , Work Instruction , Forms and Records, GBJP,
SAP, Review Curricula, Lectures competency, Learning and teaching process observation, monitoring
performance of lectures and curricula
Quality Objectives / customer survey
Animal husbandry faculty

(+) Renstra 2007-2012 was set and reviewed.
(+) Ratio of lecturer and student was on specification.
Tracer study has not been done yet. Latest result of tracer study from UB did not specify
conclusion that relate to Agriculture faculty.
Renstra has set target to evaluate English proficiency for student, i.e. TOEIC score 500. However,
similar objective that was set for lecturer has not been completed with quantitative score.
Infrastructure of teaching learning need to be improved,
Student quantity per class was big, it more than 40 though it was claimed that ratio
of student to lecturer was 1:13.
Lighting during teaching and learning in class was below standard required. It was
less than 150 Lux as required.
Teaching and learning method was not always compliance with RPKPS. As per sample
taken in class Management and IPTEK PBP, the teaching style was classical and tutorial
based rather than discussion. Lecturer role which was claimed as facilitator was not
optimal.
Where applicable, field review could be done to ensure that method of teaching has complied to
RPKPS.
Final score has component UAS, Lab activity, UTS etc. Proportion was already defined.
However, it was not always same with standard stated in Pedoman Akademik. UTS was
weighted as 25% (RPKPS) while Pedoman Akademik stated 30%. Lab activity (15% for
RPKPS) while Pedoman Akademik stated 30%.
Method of obtaining data of customer perception has not been defined in documented
procedure. It was not compliance with ISO requirements.
Note ; In actual practice, organization has monitored customer perception through student
meeting, however, this activity was not recorded and defined as official instrument to get
the data.
PKH
(+) Record of activity was well maintained. Data can be retrieved easily.
(+) Infrastructure was well maintained. Lab equipment was enlisted, maintenance schedule was
defined and well executed.
For consideration, organization need to control academic advisory activity. At current practice,
through SIAKAD, there was no control from advisor to ensure that all student has gained approval
for their RKS.
Competency requirement for the lecturer has not been defined; this was not compliance to
ISO requirement clause 6.2.2.

Assessment of: LP3 Auditee(s): Mr. Solikhin and team
Central Library Mr. Muslech and Mr. syafruddin
and team.

SK no 20/SK/ 98/ Organization structure / Annual program / Training plan and evaluation.
Library visit
LP3
(+) a lot of improvement were made; training need analysis and its planning was prepared.
Previous status of NC can be closed out.
(+) Record of activity now can be easily retrieved. Report of activity for period 2011, particularly for
training activity was completed.
There was action that not completed yet; this status has not been updated yet to Rector. See
project Kajian Pola rekrutmen & kualitas karyawan which shall be done in last March 2012.
Central Library
(+) Library has maintained implementation of quality system. Several activities that related to
survey satisfaction, control of annual action plan was done.
Assessment of: Pusat Jaminan Mutu (PJM) Auditee(s): Prof Dr. M. Bisri, and staff

Interview with management and staff,
Internal Quality Audit
Accreditation - BAN PT monitoring
PJM Program Y 2007-2012
PJM mainly has three main tasks: to develop internal quality assurance, maintain and improve university
accreditation, and to monitor and evaluate the fund and grants received for research purposes. There is a
significant improvement on the development of quality assurance indicated by the number of internal
audits commenced, and the numbers of programs which has been accredited by the government with A
classification.
There are room for improvement in PJM highlighted below:
(+) Annual action plan had been defined; control of execution of this plan was done.
Regular activity to support QMS implementation such as quality audit, accreditation progress had
been completed.
SIDEA (sistem informasi data elektronik akreditasi) application was launching officially on last 30
April 2012. It may consider to appointing certain Dept as pilot project in implementing SIDEA to
avoid frequent modification which may be never ended.
Status of accreditation regularly controlled. In 2012, it will be planned to accredit 30 PS. Status
will be checked on next visit.
Monevin activity was done as per action plan. It may consider to refining criteria used to assess
aspect of evaluation. Score used is 1 5 but basis to put score 1, 2 or 5 not clear yet. See aspect
leadership and institution, impact of program that given 2 or 3 in

Assessor: Anton Nurkholis (ID 05891)
Assessment of: BAAK Auditee(s): Mr. Agus; Mr. Imron; Mr. Ulin;
Mrs. Sestri; Mrs. Heni Hamidah;
Mr. Supardi
Guide: Mrs. Endang

Management Review
Manual mutu
Internal Audit PJM in BAAK
Survey Kepuasan Pelanggan/Indeks Kepuasan Masyarakat
Customer Complain (e-complain)
Tracer Study
Mandatory Procedure
MP Penerimaan Mahasiswa Baru Ujian Tulis (SNMPTN Ujian Tulis; SPK Ins, SPKP, SPMB)
MP Penerimaan Mahasiswa Baru Non Ujian Tulis (SNMPTN Undangan dan PSB Non Akademik)
New Organization Structure in BAAK
Laporan Penerimaan Mahasiswa Baru for SNMPTN, SPKD, SPK Ins, dan SPMK)
Daftar Program Studi dan Daya Tampung Universitas Brawijaya, Seleksi Masuk semua Jalur
tahun ajaran 2011/2012
RENSTRA in BAAK
Daftar MoU/MoU list
MoU tahun 2010, tahun 2011 dan tahun 2012
Process Flow of BAAK was shown and demonstrated. Manual mutu, Mandatory Procedure, Internal audit,
Management review, Survey Pelanggan were observed and discussed.
Others records, such as Laporan Penerimaan Mahasiswa Baru for SNMPTN, SPKD, SPK Ins, dan SPMK)
Daftar Program Studi dan Daya Tampung Universitas Brawijaya, Seleksi Masuk semua Jalur tahun ajaran
2011/2012, RENSTRA in BAAK, Daftar MoU/MoU list, and MoU tahun 2010, tahun 2011 dan tahun 2012
were observed and reviewed.
Laporan kegiatan Penerimaan mahasiswa have been reported and updated.
NC Minor was raised in BAAK (please see finding log).
Required Correction was raised in BAAK as follow:

It is recommended to review documented procedure regarding any changes in organization.
Report of Laporan Kegiatan Penerimaan could be improved by measuring time line to making
report.
Consider to be taken to review Hand over process before the job was assigned to employee. It
was observed that Hand over process was not implemented smoothly.
It is recommended to make a record for distribution of MoU copy. Current practice, there was no
evidence for this data.
It is recommended to update back up data of MoU (last updated was year 2011). It is
recommended to keep back up data in different building and record back up data activity.

Assessment of: Fakultas Ilmu Budaya Auditee(s): Mr. Rafy Anindita; Mrs. Fatimah;
Program S1 Sastra Mrs. Esther; Mr. Agus
Inggris Soeswanto; Mr. Fredy Nugroho;
Program S1 Sastra Mrs. Ummu
Jepang
Program S1 - Sastra Guide: Mr. Ahmad Witjaksono
Perancis
Program S1
Pendidikan Bahasa
Inggris
Organization of Fakultas Ilmu Budaya
Manual Mutu and Mandatory Procedure
Internal Audit by PJM in Fakultas Ilmu Budaya
Management Review
Survey Pelanggan/Customer Survey
Tracer Study
E-complain
RENSTRA Fakultas Ilmu Budaya
Competency of Lecturer and Evaluasi Dosen
MP Semester Pendek
Sasaran Mutu
Jadwal Mata Kuliah
Teaching Learning Observation
Program S1 Sastra Inggris
Program S1 Sastra Jepang
Program S1 - Sastra Perancis
Program S1 Pendidikan Bahasa Inggris
Mandatory Procedure, Survey Kepuasan Pelanggan, Customer complain (e-complain) and
records in Fakultas Ilmu Budaya were observed and discussed during assessment.
Internal Audit and Management Review were conducted and reported.
RENSTRA of Fakultas Ilmu Budaya was established and impplemented.
Competency of lecture was observed and discussed during assessment. Other records, such as
Sasaran Mutu, Jadwal mata kuliah and teaching learning in Program S1 Sastra Inggris, S1 Sastra
Jepang, S1 Sastra Perancis, and S1 Pendidikan Bahasa Inggris were observed during
assessment.
NC Minor was raised regarding Agenda of Management Review (please see finding log).
Required Corrections were raised in Fakultas Ilmu Budaya as follow:

It is consider reviewing approval from Mendikbud related to several program studies in Fakultas
Ilmu Budaya.
Update data for lecturer status for Sastra Inggris in Jadwal Kuliah and Absensi could be improved.
Current condition this data was not updated.
It is recommended to fill Form Presensi UAS/Hasil nilai completely. Some of form in Sastra
Jepang (kanji II, Kaiwa IV, Goi IV) was not filled completely.
It is recommended to review roof condition (sample was taken on Mrs. Ummu Class).

Assessment of: Fakultas Hukum Auditee(s): Mr. Ali Safaat; Mrs. Rachmi; Mr.
Program S1 Hukum Sucipto; Mrs. Femy S.; Mr.
Program S2 Suhardiyono; Mr. Edy R.; Mr. M.
Magister Ilmu Hukum, Hamidi; Mr. Iwan Permadi; Mrs.
Program S3 Endang S.; Mr. Supardi; Mrs.
Amelia; Mrs. Ikaningtyas
Guide: Mr. Ahmad Witjaksono;

Mrs. Shinta; Mr. Alfon
Organization of Fakultas Hukum
Manual Mutu and Mandatory Procedure
Internal Audit by PJM in Fakultas Hukum
Management Review
E-complain
RENSTRA Fakulta Hukum
Competency of Lecturer and Evaluasi Dosen
MP Semester Pendek
Sasaran Mutu
Jadwal Mata Kuliah
Teaching Learning Observation
Program S1 Hukum
Program S2 Magister Ilmu Hukum
Program S3
Activity of Fakultas Hukum was observed during assessment. Program S1 Hukum, Program S2
Magister Ilmu Hukum and Program S3 were observed and discussed.
RENSTRA was established in Fakultas Hukum. Mandatory Procedure, Manual Mutu were
established and implemented.
Internal audit by PJM, Management Review, Survey Pelanggan were conducted and recorded.
There was no e complain in year 2012 in Fakultas Hukum.
Several records were observed in Fakultas Hukum and Several Program Studi, such as
Competency of Lecturer and Evaluasi Dosen, MP Semester Pendek, Sasaran Mutu, and Jadwal
Mata Kuliah.
NC Minor Was raised in Fakultas Hukum (Please see finding log).
Required Correction/RC was raised in Fakultas Hukum as follow:

Evaluation of Pencapaian Renstra was not recorded.
Condition of 1st floor in Gedung B, Fakultas Hukum could be improved. Noise from outside area
came in to the class room.
Condition of chair in the class room was slightly full (no space to move on between chair.
Comfortable of Student could be improved.

Assessment of: BAK/Biro Administrasi Auditee(s): Mrs. Hernani; Mr. Widodo; Mr.
Kemahasiswaan Tjutjuk; Mr. Richard; Mr. Sagiah
Guide: Mr. Tunggul Son Haji

Process Flow of BAK
Internal audit by PJM in BAK
Management Review
E-complain
Sasaran Mutu BAK
Program Beasiswa
Laporan Pertanggung Jawaban Kegiatan

Process Flow of BAK was demonstrated and discussed during assessment. Internal audit by
PJM, Management Review, Survey Pelanggan/Customer Survey and Customer complain were
observed.
Procedure and records in BAK were observed and discussed during assessment. There was no
customer complain (e-complain) that officially recorded in BAK in year 2012.
Several program in BAK such as Beasiswa and Laporan Pertanggung jawaban were shown and
discussed.
Several NCs were raised regarding Internal Audit, Management review; Survey Pelanggan and
Sasaran Mutu (please see finding log).
Required Correction/RC were raised as follow:

New Organization structure was defined and revised; however It is recommended to review
Manual Mutu in BAK regarding new organization.
Bagian Kesejahteraan and Alumni was defined. Because of that matter, It is recommended to
make MP/Manual Procedure for Kesejahteraan and Alumni.
During assessment, Understanding of ISO 9001:2008 was observed within BAK Team. It is
recommended to provide Standard ISO 9001:2008 in BAK.
It could be useful to record realization of activity in BAK in Rencana Kegiatan untuk evaluasi
program berikutnya.
Laporan Pertanggung jawaban was made after the program was implemented. It is consider to
measure/defined the time for making Laporan Pertanggung Jawaban .
Process Monitoring for Beasiswa could be improved and recorded. It could be defined in several
steps for Beasiswa Process.

Assessment of: TIK Auditee(s): Mr. Hary Sukotjo; Mr. Arief; Mr.
Agus Naba
Guide: Mr. Tunggul Son Haji

Process flow of TIK
Internal audit by PJM in TIK
Management Review
Customer Survey and e- complain
Lembar Pelayanan Helpdesk/Work Order
Licence Software List
Back up Data
Server Room Observation
Sasaran Mutu

Activity of TIK was documented and recorded. Mandatory Procedure was also observed. Internal
audit, Management Review, and Customer survey were conducted and recorded.
Procedure and records in TIK were observed and discussed during assessment. E- complain was
improved and still under construction for new e-complain. Evidence of Back up data was
recorded. Other record, such as IT maintenance was shown and updated.
Minor NC was raised regarding Management Review (please see finding log).
Notes for improvement were raised as follow:

Helpdesk service/Pelayanan help desk could be improved by using web page.
All findings in internal audit by PJM were closed; however approval by PJM was not completed
yet.
Mirroring system for Back up data was in progress.
Development of Data Center was in progress. It is consider optimizing Data Center for other
purpose (MoU and Other purpose).
Server room temperature was monitored by Thermometer. It is consider implementing
temperature of server monitoring system by alarm/lamp.

Assessment of: LPPM Auditee(s): Prof. Dr. Ir. Siti
Chuzaemi. MS
Prof. Dr. dr.
Noorhamdani A.S. Sp.
MK
Quality Objective
Management Review
Internal Audit
Corrective and Preventive Action
Competency and awareness
Document and record control
Infrastructure/Facility
Customer satisfaction
Procedure MEMPROSES INFORMASI PENELITIAN DAN PENGABDIAN MASYARAKAT.
Instruksi Kerja pada sub bag progam (IK 00007, 030000)
Instruksi kerja keuangan
Sample Info program unggulan berpotensi HKI
Rincian kegiatan perawatan

Refer to the last audit report, the continual improvement was found in LPPM which is good
improvement :
o Target related customer satisfaction for penelitan dan pengabdian masyarakat had been
defined.
o The procedure of MEMPROSES INFORMASI PENELITIAN DAN PENGABDIAN
MASYARAKAT had been detailed to show who, how and when.
Management Review and internal audit had been conducted as per schedule. The implementation
of these activities found complies. Corrective and preventive action was demonstrated.
Required correction :
Program for maintenance had been shown; however there was no report that
demonstrated the implementation had been conformed to the plan.
Quality objective had been established and measured. In general, already confirmed to the
mission of LPPM. However the objective of finance (keuangan) was not established yet.

Assessment of: FIA Auditee(s): Prof. Dr. Sumartono (Dean)
Jurusan Administrasi and team
Bisnis (S1)
Jurusan Ilmu
Administrasi (S3)

Pengukuran Kepuasan Pelanggan (EDOM);
Infrastructure maintenance
Jadwal Mata Kuliah S3
Pedoman Mutu
Berita acara perkuliahan.
Kurikulum
Evaluasi kinerja dosen.
Kepuasan pelanggan per semester
Proses belajar mengajar.
Customer satisfaction measurement had been conducted on December 2011. A minor weakness
found in responding the result the measurement. Required correction: Response to customer
satisfaction measurement. Please records the corrective actions plan/monitoring. The
activities of result of EDOM for example for the topic cleanness, LCD, teaching learning
schedule changing.
In term of Pendidikan the customer satisfaction measurement had been established and
implemented. But not yet for Pengabdian dan Penelitian. Please see assessment finding
log.
Last Management review meeting was conducted on 18 March 2012; the input of meeting
was not complete. Please see assessment finding log.
Infrastructure. Although the activities of maintenance could be shown by documented
evidence, but there was no plan/program for doing the maintenance. This is a required
correction.
Teaching and learning design and process had been reviewed and found in order.

Assessment of: FISIP Auditee(s): Prof. Dr. Ir. Sanggar Kanto, MS
Sosiologi and team
Ilmu komunikasi
Psikologi
Hub Internasional
Ilmu Politik
Ilmu pemerintahan
Internal Audit
Management review
Jadwal Kuliah
Rpkps
Pedoman Pendidikan
Infrastructure
Teaching learning process
Internal Audit was conducted on 1 March 2012 at faculty level. In general the activities was
complying the standard.
Last management review was conducted on April 2012; it was found the input of review was not
completed. Please see assessment finding log.
Infrastructure maintenance was not determined yet, and there was no evidence for
implementation. Please see assessment finding log.
Teaching learning process had been review for all department and in general found in order and
under control.
Assessment of: BAKP (Biro Administrasi Auditee(s): Mr. Imam Syafei SE, MM and
Keuangan dan Perencanaan) team

Laporan realisasi penggunaan dana BNP
WTP (Wajar Tanpa Pengecualian-----audit KAP): Tahun 2011.
Tahun 2011: peringkat 1 dalam tindak lanjut BPK.
Laporan keuangan
Sasaran mutu
Surat pernyataan tanggung jawab belanja
Standard Pelayanan Di bagian akutansi BAKP
A good point that the department get the level of WTP (Wajar Tanpa Pengecualian) for financial
report 2011 audited by KAP and rank number 1 (Peringkat 1) in following up finding from BPK.
An improvement found that the department show a standard service (Standard Pelayanan).
However the standard should be approved by the head of department. The socialization
must also be socialized. Further the standard should be measured. (Required correction).
Formerly the department was only responsible for Financial Administration (Administrasi
Keuangan). The Planning (Perencanaan) was merged to this department just in 17
February 2012. The procedure and establishment related Perencanaan should be
existed.
Archiving the file, such as financial report, contract etc was very importance for this
department. The method or the procedure of archiving should be established. Please see
assessment finding log.

Assessment of: Biro Administrasi Umum dan Auditee(s): Dra. Sukowinarti and team
Kepegawaian (BAUK)

Pemeliharaan asset, Sarana dan Rumah tangga (Kebersihan, kemanan, pertamanan)
Kepegawaian
Protokoler
Tata usaha dan hukum tata laksana
Laporan Kegiatan rutin petugas kebersihan dan pertamanan
Jadwal piket satpam.
Laporan kegiatan rutin petugas sampah
Although the report regarding maintenance can be shown, however there was no program
for maintenance for example maintenance AC. (Required Correction)
The planning of management review interval established once per month. However there
were no activities for management review during 2012. Please see assessment finding log.
Assessor: Dede Gunawan (ID 04315)

Assessment of: Fakultas Teknologi Pertanian Auditee(s): Dr.Ir. Bambang Susilo, M.Sc.Agr
(Dekan), Dr. Ir. Bambang Dwi
Argo, DEA, Dr. Ir. Elok
Zubaidah, Dr.Ir. Ruslan Eiro
Seodarmo, Dr.Ir. Nur Hidayat,
MS, Dr. Teti Estiasih, STP, MP,
MAsud Efendi, STP, MP, Dr.
Panji Deoranto, Dr. Ir. Agustine
Dr.Ir. Teny, Dr.Ir Widya Dr,dr.
Loeki Engkar Fitri, MKes,
SpParK (Guide)
Review Implementation of Quality Manual, Procedure , Work Instruction , Forms and Records, GBJP,
SAP, Review Curricula, Lectures competency, Learning and teaching process observation, monitoring
performance of lectures and curricula at
1. Fakultas Teknologi Pertanian (Renstra)
2. Ilmu dan Teknologi Pangan (S1)
3. Ilmu dan Teknologi Pangan (S2)
4. Keteknikan Pertanian (S1)
5. Teknologi dan Industri Pertanian (S1)
6. Teknologi dan Industri Pertanian (S2)

Fakultas Teknologi Pertanian (Renstra)
The faculty have a clear vision, mission, objectives and target set for 2008 to 2012 and program to
achieve its objectives and target.
Achievement also was monitored though some objective of Faculty performance has not met the target
while other was well achieved i.e. IPK , Time to finish study less than 4 Y.
Some correction was issued as follow :
Current Faculty Strategic Planning (Renstra) still was not fully link to UB Vision i.e. Entrepreneur
University; Next Renstra 2012-2016 still in development process, according to auditee
entrepreneurial aspect will be included. (It will be verified during next visit)
Quality objective that measure study completion need to be calculated in percentage rather than
year duration in order to easily get big picture of achievement.
Achievement target was monitored however analysis and corrective or preventive action taken
need to be provided in systematic record.
Root-cause analysis and corrective or preventive action of resulted from student satisfaction
survey need to be reported in more comprehensive.
Ilmu dan Teknologi Pangan (S1) and (S2)

some International achievements were demonstrated , All Lecturers are S2-S3 grade
Traceability of documentation of Education planning and execution since Curriculum, SAP,
implementation and evaluation was well traced
Method of study evaluation was defined however the score calculation that use proportional
system need to be defined in current SAP
Laboratorium facilities:
One minor was issued related to Laboratorium facilities see in finding log and noted as as below :
ISO 17025 principles recommended to be implemented in Food Quality Laboratory
Keteknikan Pertanian Pangan (S1)

BAN PT was GRADE A and Lecturer competence (S2-S3) was fully fulfilled
Root caused analysis and action plan of any changing total score need be officially reported; see
lesson of Ekonomi Teknik which initially had of score C but then in final score it become A or
B+.
Hand out of material study form Practitioner lecturer need to be maintained i.e. Kewirausahaan
Agribisnis
Teknologi Industri Pertanian

Entrepreneurship concern was demonstrative in curriculum
Method of study evaluation was defined however the score calculation that use proportional
system need to be defined in current SAP.
Drop out level need to be defined as one of quality objective considering that there were 40 cases
of students drop out in 2011.
Target IPK > 3 need to be reviewed and matched to BAN PT requirement.
Procedure and Recorded evidence of Preventive maintenance of computer at Laboratory TIP
was not found
Teknologi Industri Pertanian (S2)

Vision and mission of S2 TIP was not fully follow the UB vision
Different requirement for TIP - S2 student recruitment was found in Leaflet and register form i.e.
form TOEFL (500) TPA (450) Leaflet TOEFL 480 TPA 500
Requirement of 80 % student present for final test was not achieved and no justification made to
allow respected student to join the examination.

Assessment of: Poliklinik Auditee(s): Dr Tini SpPK, dr. Farid, dr.Didy
Fajar, Mr. Elisa and other staff.

Review Implementation of Visi dan mission, Procedures, Work Instruction, Forms and Records,
observation to pharmacy, laboratory, and day care facility.

Policlinic was intended to support civic academia: student and lecture, family and for publics, to give an
easy access to the health services. There are three main businesses of the services: Polyclinic Gigi,
Poliklinik Umum, bagian Gizi, one day care and home care. It is supported with pharmacy, and medical
laboratory.
Policlinic activities since registration, services to be reporting were well done better than previous audit.
And previous finding was follow up but still in process Recorded evidence also was well shown:
However some required correction were noted as follow:
Its recommended provided that a pharmacist as pharmacy PICs as per regulation
Refrigerator for Serum and reagent storage temp of freezer and temp was not controlled yet
Expired Date of Codein was not defined yet
Currently customer satisfaction survey was done in monthly bases with result is similar the
frequency need to be reviewed i.e. yearly
Management review meeting need to be fully followed the Requirement i.e. corrective &
preventive action , process performance

Assessment of: Job Placement Centre Auditee(s): Dr. Nia Kurniawan, Mr. Widi, Mr.
Hadi

JPC facility
Service process
Employee candidate datas
Customer survey
JPC facility was found that convenience ,
JPC services were demonstrated since request to be hand over included customer satisfaction survey.
Previous finding was verified and closed ,
Data base of candidate was well maintained
Objective ,monitoring need to be done consistently
competency Matrixs of JPC staff need to updated as per current organization since some the
staff is new
Effectiveness JPC program need to be evaluated after executed to ensure that efficiency program
as per objective i.e. Job fair
Assessment of: Satuan Pengawas Internal Auditee(s): Mr. Prapto Mr, Rudy and other
(SPI) staff

SPI audit program
Audit report
Followed up monitoring
Procedure, Work Instruction, Forms and Records of SPI .
There are five areas of internal audits: Human Resources (SDM), Facility (Sarana dan Prasarana), Civil
and Buildings, Finance and Information Technology. Different standard of audits were used as a standard
requirements in the audit process.
Program SPI was established and Y 2012 most of Faculty already audited , risk base analyses was done
However one minor was issued and some correction need to be taken was noted as below:
Competence SPI assessor need to be defined more specifically as per field i.e. Finance IT,
Human resources, Infrastructure
Audit Planning need to be monitored the Actual since some planning was delay i.e. LSIH audit on
Jan 2012
Risk Base analysis recommended to be defined in more specific each field i.e. Human resources
FKH instead of all FKH faculty
Customer satisfaction survey was done however it need to be analyzed and concluded

Assessment of: LSIH Auditee(s): Prof. Dr. Yenny Sri Winarsih,
Prof Dr. Kuswanto , Dr.
Nurhidayat, Dr. Jhony, Dr. Yuni

Vision and Mission
Objective monitoring
Procedure
Register process
Calibration status
Site audit
LSIH current already have 17025 accreditation , all measuring equipment were calibrated , competence
of personnel was demonstrated and All previous finding was followed up and closed
However some correction were identified as below:

Temperature monitoring for refrigerator for Sample and reagent storage need to be taken to
ensure that temp as per requirement i .e. Lab Chemical and microbiology
Expired reagent was found at Micro lab i.e. Levine (2011)
Re-test of chemical reagent for expired reagent was done on 2008 however the retest need to be
taken immediately
Result of daily QC need to be concluded i.e. Protein test
Aquadest quality s as reagent solution need to be tested
Microbiology testing environment need to be controlled periodically to ensure condition of proper
testing
Re-testing procedure need to be taken including result justification
Service registration at LSIH recommended using computerized system instead of manually to
prevent wrong registered

3. Assessment Findings Log - ISO 9001:2008
Grade Status Finding Corrective action review Process / aspect Date Reference Clause
1 2 3 4 5 6 7 8
Minor NC Open There was no evaluation on achievement of Renstra 2007- (RAZ 9 May 12) : verification at other faculty FK - Strategic Planning 12 Oct 11 1110RAZ01 5.4
2012 though this activity stated as one of mandatory activity. shown that this action not effective yet; see finding
Annual program 2011/2012 was not available as record of at Faculty of animal husbandry.
strategy deployment from University to faculty. (Note: Later,
organization has completed it).
It was also observed that entrepreneurship that was
defined as one of vision of university has not included yet into
Faculty Renstra. There was no aspect that deployed and
refers to this aspect. In overall, strategy deployment from
University to faculty and PS has not been done properly.
Minor NC Closed Criteria to accept student at PBL phase has not been define RAZ (9 May 12) : Corrective action was taken, Gizi 12 Oct 11 1110RAZ02
in current Manual Procedure. This criterion was available on previous NC corrected.
Student Guideline document but this document has not
included yet as one of official document of this faculty.
There was no clear mechanism to manage final score
resulting from remedial and short semester program. See
final score of certain student for major AnFis and BioKimol
that change from E to C without proper record of remedial.
According to auditee, the respective lecturer has informed to
admin staff via phone call.
Infrastructure has not been controlled in regard to lighting,
safety (electrical plug) at Lab BioKimol.
Minor NC Closed Process of curriculum development has been done with RAZ (9 May 12) : Corrective action was taken, PD 13 Oct 11 1110RAZ03 7.3
output document called Pedoman akademik PS PD previous NC corrected.
2010/2011. It was noted that
Point of changes in this document has not been identified
and recorded as required by ISO 9001:2008 clause 7.3.
There was no evidence can be demonstrated that input of
design curriculum was available (such as feedback from user,
student, evaluation of previous curriculum implementation).
Pedoman akademik has not been identified as quality
record that shall be maintained.
Academic year 2011-2012 has been on going but Pedoman
Akademik still use 2010/2011 period.
Note: Later, PD has completed this document.
1. Grading of the finding * 2. New, Open, Closed 3. Description of the LRQA finding 4. Review by LRQA 5. Process, aspect, department or theme
6. Date of the finding 7. YYMM<Initials>seq.# 8. Clause of the applicable standard
* Major NC = Major nonconformity Minor NC = Minor nonconformity RC = Requires correction SFI = Scope for improvement xLRQA = Issue for follow-up by LRQA at next visit

1 2 3 4 5 6 7 8
Minor NC Open There was no defined method to measure and analyze RAZ (9 May 12) : Corrective action taken, but Kebidanan 14 Oct 11 1110RAZ04 8.2.1
customer satisfaction perception though organization has similar problem was recur at other area, See
conducted student hearing on last Sept 2011. this was not faculty of animal husbandry.
compliance to ISO 9001:2008 requirement clause 8.2.1.
Organization has defined quality objective that relate to
customer satisfaction; however, measurement of this
objective has not been done. See quality objective of
customer satisfaction that was set at 80%.
Class observation was done and there was no discrepancy
found unless recommendation to compile lecture material
immediately, not waiting until lecture period finished.
Minor NC Closed Pedoman akademik that was defined as reference to RAZ (9 May 12) : Corrective action was taken, Kebidanan 14 Oct 11 1110RAZ05 7.5
conduct teaching and learning process has not been previous NC corrected.
established for 2011/2011 academic year. Latest Pedoman
Akademic was established for 2009/2010 period.
Kurikulum 2011/2012 was defined to have 143 SKS for
graduate level though Pedoman Akademik 2009/2010 has
stated 144 SKS as minimum credit to get S1 strata.
There was no academic advisor appointed for the new
student 2011/2012 period though Pedoman academic has
stated that appointment of them.
Not all RPKPS have been developed that cover all period of
academic year. See RPKPS from 6th semester to 8th
semester that was not developed yet.
Minor NC Closed Not all mandatory documented procedure has been RAZ (9 May 12) : Corrective action was taken, Kebidanan 17 Oct 11 1110RAZ06 4.2.2
established such as Internal audit. previous NC corrected. 5.6
MRM that required by ISO standard has not been 5.4
completed. There was regular review but no action planned,
due date and person in charge documented in official minute
of meeting. (Note: Later, minute of meeting was prepared).
Quality objective has been defined but monitoring of actual
result has not been completed. See all quality objectives such
as ratio of lecturer and student, percentage of lecturer with S2
and S3 degree etc.

1 2 3 4 5 6 7 8
Minor NC Open Composition of final score that consist of examination and RAZ (9 May 12) : Corrective action taken, but Keperawatan 17 Oct 11 1110RAZ07 7.5
assignment was not always consistently followed. See similar problem was recur at other area, See 7.6
English for Nurse subject that has 60% for exam, 5% for faculty of animal husbandry.
Present and 35 for assignment while Pedoman Akademik
stated 70% for examination and 30% for assignment (for
subject that has no laboratory practice).
Validation for test material has not been done though the
manual procedure required it. The validation was only
completed for answer sheet from student. (Note : Later, this
document was completed).
Minor NC Closed Academic advisor has not been defined and established for RAZ (9 May 12) : Corrective action was taken, Gigi 17 Oct 11 1110RAZ08 7.5
new student (academic year 2011/2012). According to previous NC corrected.
auditee, this process was responsibility of Dean of Faculty.
On the other hand, Pedoman Akademik stated that this
activity was responsibility of Head of PS.
Some documented procedure has not been developed yet
such as internal audit, doc control etc. Manual mutu was
available but still not officially released.
Minor NC Closed Input of process has not been defined and identified with RAZ (9 May 12) : Corrective action was taken, LP 3 11 Oct 11 1110RAZ09 5.4
specific flow. See training need analysis that still done based previous NC corrected.
on information received during Management meeting. There
was no specific mechanism to identify training need from
other faculty or bureau within university.
Quality objective was not always controlled. See evaluation
of KBK that was not completed yet. (Note: Later, LP3 has
been completed the manual procedure to evaluate KBK,
evaluation report still not done yet).
Not all of quality objective was under control of LP 3. See
quality objective that related to teaching learning that use
multimedia which is the control is belong to respective faculty
or lecturer.
Minor NC Closed There was no control to external document that was used RAZ (9 May 12) : Corrective action was taken, LSIH 18 Oct 11 1110RAZ10 4.2.2
as official reference for organization to conduct the process of previous NC corrected.
business. See ISO 17025, SNI 01-2891 standard etc.
Not all part of documented procedure, particularly flow
chart, that legible. Quality of copy was poor. See all manual
procedure.
Work instruction that contain coding method for sample
analysis has not been officially issued.

1 2 3 4 5 6 7 8
Minor NC Closed Work environment was not always controlled to ensure that RAZ (9 May 12) : Corrective action was taken, LSIH 18 Oct 11 1110RAZ11 7.6, 6.3
it will not impact to quality analysis. There was no standard previous NC corrected.
for temperature and humidity of Laboratory.
An acceptance criterion has not been defined to judge
whether the calibrated equipment status is OK or not. See
distillation and titration unit that was reported has uncertainty
level 0.02 PH and not decided yet whether this level is
acceptable or not. It needs to be reviewed whether the
uncertainty due to warm temperature (24 Celsius degree).
Expiry period for reagent that used for analyzing the sample
was not defined yet.
Minor NC Closed Manual procedure has not been defined for process of RAZ (9 May 12) : Corrective action was taken, JPC 18 Oct 11 1110RAZ12 7.5
quotation and invoicing. It was observed some invoicing to previous NC corrected.
certain client could not be evidenced. See client Honda
Prospect Motor, Kalbe Nutritional.
Minor NC New Infrastructure of teaching learning need to be improved, Animal Husbandry 10 May 12 1206RAZ01 7.5
Student quantity per class was big, it more than 40
though it was claimed that ratio of student to lecturer
was 1:13.
Lighting during teaching and learning in class was
below standard required. It was less than 150 Lux as
required.
Teaching and learning method was not always compliance
with RPKPS. As per sample taken in class Management and
IPTEK PBP, the teaching style was classical and tutorial
based rather than discussion. Lecturer role which was
claimed as facilitator was not optimal.

4. - SUB REPORT ISO 9001:2008
1 2 3 4 5 6 7 8
Minor NC New Procedure and Recorded evidence of Preventive TIP-Computer maintenance 10 May 12 1205DGX02 6.3
maintenance of computer at Laboratory TIP was not
found
Minor NC New Checklist audit was not used during audit at FKH SPI-various 11 May 12 1205DGX03 7.5.1,
audited as per Procedure i.e. 5. Checklist Human 5.4.1
Resources
IT checklist Audit as guidance during auditing was not
found in current procedure (00010-02-008)
SPI Objective was established however it was not
minored yet. i.e. objective 2011-2012
Minor NC Open Currently policlinic services covered also for public and Point -3-4 already followed up prior closing Policlinic 24 Oct 11 1110DGX19 6.3.
insurance but have no a permit from regulator meeting however for point 1-2 still in process
Some measuring equipment was not calibrated yet ;pipette, Calibration and permit form regulator still in
tensimeter, weighing scale only by Supplier process hence this finding still open
Expired Medicine and Reagent were found i.e. Widal, (2007)

blood test (2010), corsabitol ( August 2011) ( It was followed
up prior closing meeting)
Recorded evidence the Daily QC of Cobas, prior analysis as

per work instruction was not found
Minor NC Closed The forms and records shown in the audits process were not Action plan has to be made by auditee and send SPI 18 Oct 11 1110JKADGX 4.2.3
controlled document for example Laporan Hasil Audit (LHA to LRQA within 90 days from closing meeting. The /FBZ18
and LHR), audit questionnaires and borang-borang. action plan consist of investigation of root cause
problem and corrective action to be taken.
10/05/2012 (DGX) The corrective action was
taken reviewed and closed

Minor NC Closed Audit frequency, duration and exceptions condition which Action plan has to be made by auditee and send SPI 18 Oct 11 1110JKADGX 8.2.2
can affect audit plan, and auditor competencys to LRQA within 90 days from closing meeting. The /FBZ17
requirements has not been defined the procedure of audit action plan consist of investigation of root cause
Audit Chapter Doc no 0001001000 Rev 2, dated on 19 problem and corrective action to be taken.
Sept 2011. 10/05/2012 (DGX) The corrective action was
Integrated audit was initially planned to be conducted in
February 2011, however it was delayed for five months to
August, 2011
Minor NC Closed There was no requirements has been set to ensure that Action plan has to be made by auditee and send PJM 18 Oct 11 1110JKADGX 8.2.2
time to reporting audit result, and time to response corrective to LRQA within 90 days from closing meeting. The /FBZ16
actions are taken without undue delay. action plan consist of investigation of root cause
problem and corrective action to be taken.
The audit summary was not supported by the audit forms
which define corrective actions and their causes, and 10/05/2012 (DGX) The corrective action was
Follow-up activities were not including the verification of the taken reviewed and closed
actions. Some evidences are: audit conducted in June 15,
2011 to Faculty of Economy, and June 17, 2011 to Jurusan
Ekonomi
Minor NC Closed There was a meeting in 3 March 2011 discussing Action plan has to be made by auditee and send Jurusan Akuntansi 17 Oct 11 1110JKADGX 5.6.2
preparation of the new semester and another meeting to LRQA within 90 days from closing meeting. The /FBZ15
(without date) discussing 11 agenda, however feed back action plan consist of investigation of root cause
from student, status of corrective and preventive action, problem and corrective action to be taken.
follow-up actions from previous management reviews and 10/05/2012 (DGX) The corrective action was
internal audit findings were not discussed in the meeting taken reviewed and closed
and recorded in the minutes.
Minutes of meeting only stated bullet point of the item

discussed and there was no explanation of the items had
been discussed.
The format of the minutes of meeting could be structured
better by adding column of discussion, person in charge,
date expected of corrective action plan/taken and the status
of items discussion

Minor NC Closed Tutors performance is available for Semester 1 Year Action plan has to be made by auditee and send Jurusan Akuntansi 17 Oct 11 1110JKAESX/ 8.4 a
2010/2011. A sample was taken of Dr. Ali Djamhuri, and he to LRQA within 90 days from closing meeting. The FBZ14 8.4. b
was rated high by the student: .4.17 (max 5) as a result of an action plan consist of investigation of root cause
averages value of Akuntansi Lanjut, Audit Laboratory, and problem and corrective action to be taken.
Management Lintas Budaya. In some points in the 10/05/2012 (DGX) The corrective action was
questionnaires he was rated 3, and It was not found in taken reviewed and closed
details the data evaluation and analysis, corrective action
plan and the status of the subject when he was rated low by
the student, for tutor performance improvement.
It was found in the Renstra 2007 to 2009 (page 15), there

was a decrease significantly in the number of student
interested to study in under graduate program, however
there was no analysis to evaluate the data.
It was found that IPK was summarized very briefly only on

the average, and there was no further evaluation on the IPK
to give a comprehensive analysis on the IPK, whether it is
distributed normally or need further improvement. For
example Murih Yuwono has IPK 2.86 and he was just
passed paper test for undergraduate student, although the
IPK is below average.
Minor NC Closed Management Review has been conducted in 25 Feb 2011, Action plan has to be made by auditee and send S2 MM (Magister of 14 Oct 11 1110JKAFBZ 5.6.2
however feed back from student, status of corrective and to LRQA within 90 days from closing meeting. The Management) 13
preventive action and follow-up actions from previous action plan consist of investigation of root cause
management reviews and internal audit findings were not problem and corrective action to be taken.
discussed. 10/05/2012 (DGX) The corrective action was
of items discussion
Minor NC Closed It was found in the Renstra the data collection and analysis Action plan has to be made by auditee and send S2 MM (Magister of 14 Oct 11 1110JKAESX/ 8.4.a
for timelines of study, IPK and number of student for the to LRQA within 90 days from closing meeting. The Management) FBZ12 8.4.c
year 2007 to 2009; however there was no data analysis for action plan consist of investigation of root cause
those indicators in year 2010 and 2011, to see the trend and problem and corrective action to be taken.
improvement.
There was Evaluation written for lecture Noermijati in year taken reviewed and closed
2010/2011, however The data collected in the Evaluasi
Kinerja Dosen was not analyzed and evaluated for further
improvement.

Minor NC Closed Management Review has been conducted in 23 March 2011 Action plan has to be made by auditee and send S2 PMIE (Magister of 14 Oct 11 1110JKAFBZ 5.6.2
and 26 Aug 2011, however feed back from student, status of to LRQA within 90 days from closing meeting. The Economics) 11
corrective and preventive action and follow-up actions from action plan consist of investigation of root cause
previous management reviews were not discussed. problem and corrective action to be taken.
The format of the minutes of meeting could be structured taken reviewed and closed
of items discussion
Minor NC Closed It was found in the Renstra the data collection and analysis Action plan has to be made by auditee and send S2 PMIE (Magister of 14 Oct 11 1110JKAESX/ 8.4.a
for timelines of study and IPK for the year 2007 to 2009; to LRQA within 90 days from closing meeting. The Economics) FBZ10 8.4.c
however there was no data analysis for those indicators in action plan consist of investigation of root cause
year 2010 and 2011, to see the trend and improvement. problem and corrective action to be taken.
There was no Evaluation written for lecture Dwi Budi 10/05/2012 (DGX) The corrective action was
Santoso SE, MS, PhD from student and also it was not taken reviewed and closed
found in the Summary or Rekap Evaluasi Kinerja Dosen in
year 2010/2011.
The data collected in the Rekap Evaluasi Kinerja Dosed was

not analyzed and evaluated for further improvement.
Minor NC Closed Management Review has been conducted in 10 Nov 2010, Action plan has to be made by auditee and send Ph D Management Program 13 Oct 11 1110JKAESX/ 5.6.2
however feed back from student, status of corrective and to LRQA within 90 days from closing meeting. The FBZ09
preventive action and follow-up actions from previous action plan consist of investigation of root cause
management reviews were not discussed. problem and corrective action to be taken.
The format of the minutes of meeting could be structured 10/05/2012 (DGX) The corrective action was
better by adding column of discussion, person in charge, taken reviewed and closed
of items discussion
Minor NC Closed Tutors performance is available for Semester Ganjil Year Action plan has to be made by auditee and send Ph D Management Program 13 Oct 11 1110JKAESX/ 8.4 a
2010/2011. Three samples was picked : Prof Eka Afnan, Dr to LRQA within 90 days from closing meeting. The FBZ08
Mintarti Rahayu, and Prof Armanu. They were rated high by action plan consist of investigation of root cause
the student: .4.9, 4.5 and .4.8 in the scale of max 5. There problem and corrective action to be taken.
were also suggestions listed for the tutors concerning the
teaching learning method and tutors soft skills; however 10/05/2012 (DGX) The corrective action was
there was no evidence showed that the suggestions have taken reviewed and closed
been discussed and evaluate for tutor performance
improvement.

Minor NC Closed There were 40 student feedbacks of various matters during Action plan has to be made by auditee and send Jurusan Management 12 Oct 11 1110JKAESX/ 8.4 a
August 2010 to September 2011 captured in web based - to LRQA within 90 days from closing meeting. The FBZ07
online SISKA - and there was no procedure and standard action plan consist of investigation of root cause
service to response the input from student. problem and corrective action to be taken.
The data have been collected to figure the performance of 10/05/2012 (DGX) The corrective action was
tutors every year, for example it was found that in Ilmu taken reviewed and closed
Manajemen Atim Djazuli has index of 32 SKS compared to
the requirements 12 18 max SKS the tutor can teach,
however there is no evaluation where actions needs can be
made for continual improvement.
Minor NC Closed There is a documented procedure established to define the Action plan has to be made by auditee and send Jurusan Manajemen 12 Oct 11 1110JKAESX/ 4.2.4
record controls, however the list of records has not been to LRQA within 90 days from closing meeting. The FBZ06
completed with identification, storage, protection, retrieval, action plan consist of investigation of root cause
retention time and disposition of records. problem and corrective action to be taken.

Minor NC Closed Management Review has been conducted in several Action plan has to be made by auditee and send Jurusan Manajemen 12 Oct 11 1110JKAESX/ 5.6.2
meetings, 7 Feb 2011, 13 April 2011, 2 May 20011, and 6 to LRQA within 90 days from closing meeting. The FBZ05
June 2011, however feed back, process performance, action plan consist of investigation of root cause
status of corrective and preventive action and follow-up problem and corrective action to be taken.
actions from previous management reviews were not
discussed. 10/05/2012 (DGX) The corrective action was
of items discussion
Minor NC Closed Management Review has been conducted in several Action plan has to be made by auditee and send Jurusan Ilmu Ekonomi 11 Oct 11 1110JKADGX 5.6.2
meeting during 2011 however feed back, process to LRQA within 90 days from closing meeting. The /FBZ04
performance, status of corrective and preventive action was action plan consist of investigation of root cause
not discussed in the meeting. problem and corrective action to be taken.
The format of the minutes of meeting could be structured 10/05/2012 (DGX) The corrective action was
better by adding column of discussion, person in charge, taken reviewed and closed
of items discussion

Minor NC Closed Data Analysis and of monitoring of the measurement was Action plan has to be made by auditee and send Jurusan Ilmu Ekonomi 11 Oct 11 1110JKAFBZ 8.4 a,
not fully implemented, for example: to LRQA within 90 days from closing meeting. The 03 8.4. b
a. Time to finish study less than 4 years is conducted action plan consist of investigation of root cause
every semester, and the number for 2011 is 30%, problem and corrective action to be taken.
however it is not stated clearly whether the number is
a target or actual achievement. 10/05/2012 (DGX) The corrective action was
b. The number of student who finish the study less than taken reviewed and closed
4 years in 2010 was 29,5% while in 2009 is 34,8%,
however there is no documented root-cause analysis
and corrective or preventive action taken.
c. It was discussed that one contributing factor that
affecting the timeliness of study is score of TOEFL.
The LDC is provided to the student, and so far no data
available whether the LDC is an effective corrective
answer to the timeliness of the student to finish the
study.
d. The number of drop out is considered small 0.89%.
Preventive action was taken by sending letter to the
students and his/her parents. Fifteen students with
bad record of academic index was invited to the
meeting in Feb 17, 2011 to prevent the number of
drop out from being increase, and only five attended
the meeting. List of attendance is available (dated on
th
May 30 2011). The discussion during the meeting
was not recorded.
e. The Number of student who has academics index
more than 3,00 at the end of semester 2010/ 2011
was not available yet. The number of student with
academic index < 2.75 in 2010/2011 compared to
2009/2010 was increased from 0 to 5,
Minor NC Closed Management Review has been conducted in Action plan has to be made by auditee and send Fakultas Ekonomi 11 Oct 11 1110JKADGX 5.6.2
to LRQA within 90 days from closing meeting. The /FBZ02
several meeting during 2011:3 January, 15
action plan consist of investigation of root cause
March, , 23 May, 15 July, 24 Aug (Internal problem and corrective action to be taken.
Audits) and 5 April (Organizational change),
however feed back, process performance, status 10/05/2012 (DGX) The corrective action was
of corrective and preventive action was not
discussed.
The format of the minutes of meeting could be

structured better by adding column of
discussion, person in charge, date expected of
corrective action plan/taken and the status of
items discussion.

Minor NC Closed The input of the feedback data has not been Action plan has to be made by auditee and send Fakultas Ekonomi 11 Oct 11 1110JKADGX 8.4.a
analyzed (categorized, percentage). For to LRQA within 90 days from closing meeting. The /FBZ01
action plan consist of investigation of root cause
example feedback from Reny Yustina NIM problem and corrective action to be taken.
0910230115 in Sept 9, 2011 about schedule has
not been responded. 10/05/2012 (DGX) The corrective action was
Minor NC Closed Data Analysis and of monitoring of the measurement was Action plan has to be made by auditee and send 24 Oct 11 1110DGX01
not fully implemented, for example: to LRQA within 90 days from closing meeting. The
f. Time to finish study less than 4 years is conducted action plan consist of investigation of root cause
every semester, and the number for 2011 is 30%, problem and corrective action to be taken.
however it is not stated clearly whether the number is
a target or actual achievement. 10/05/2012 (DGX) The corrective action was
g. The number of student who finish the study less than taken reviewed and closed
4 years in 2010 was 29,5% while in 2009 is 34,8%,
however there is no documented root-cause analysis
and corrective or preventive action taken.
h. It was discussed that one contributing factor that
affecting the timeliness of study is score of TOEFL.
The LDC is provided to the student, and so far no data
available whether the LDC is an effective corrective
answer to the timeliness of the student to finish the
study.
i. The number of drop out is considered small 0.89%.
Preventive action was taken by sending letter to the
students and his/her parents. Fifteen students with
bad record of academic index was invited to the
meeting in Feb 17, 2011 to prevent the number of
drop out from being increase, and only five attended
the meeting. List of attendance is available (dated on
th
May 30 2011). The discussion during the meeting
was not recorded.
The Number of student who has academics index
more than 3,00 at the end of semester 2010/ 2011
was not available yet. The number of student with
academic index < 2.75 in 2010/2011 compared to
2009/2010 was increased from 0 to 5, however
without data analysis and corrective action taken
reported.
j. There are sixty two (62) feedbacks from student of
Economics, from August 2010 Sept 2011 and it was
not categorized and analyzed for corrective action,

Minor NC New Some deficiency were noted at food quality Laboratory - TIP- Laboratorium Facilities 10 May 12 1205DGX01 6.3, 7.6
ITP :
Calibration of measuring equipment at
microbiology which using for Analysis was not
taken i.e. incubator, weighing scale , and Food
Quality testing laboratory i.e. thermometer, Ph
meter , pressure gauge etc
Some expired reagent were found i.e. Pati, NaOH
expired since 2006
Cleanness of Food quality Laboratory need to be
improved since some web spider was observed

5. Assessment Findings Log - SUB REPORT ISO 9001:2008
1 2 3 4 5 6 7 8
Minor NC New Archiving the file, such as financial report, contract etc was BAKP/Method of archiving 11 May 12 1205SHS01 4.1.C
very importance for this department. The method or the
procedure of archiving should be established.
Minor NC New Infrastructure: Although the result of activities of FISIP/Infrastructure 11 May 12 1205SHS02 6.3
maintenance could show by visit for example good
condition AC, cleanliness of room toilet and, good lamp,
there was no documented evidence that the maintenance of
infrastructure had been determined and provided.
Minor NC New There was no method established how to measure FIA/Customer Satisfaction 11 May 12 1205SHS03 8.2.1
customer satisfaction in term of pengabdian masyarakat
and penelitian

1 2 3 4 5 6 7 8
Minor NC Closed It was found the SAP/ RPKPS was not complete. From 10 RAZ (9 May 12) : Corrective action was taken, Fakultas Teknik/Teaching 19 Oct 11 1110SHS01 7.3
samples found 2 of MATA KULIAH (course subjects) had no verification at other area shown that recurrence Learning
SAP i.e FISIKA I (MK TKM4105) for Monday 10 October 2011 problem not found; therefore status can be closed
and KALKULUS (TKM4101) for Tuesday 11 October 2011. out.
This was not complying with procedure Perkuliahan. (Jurusan
TEKNIK MESIN)
Minor NC Closed It was found some of the equipment not identified as listed on RAZ (9 May 12) : Corrective action was taken, Fakultas Teknik/Facility 19 Oct 11 1110SHS02 6.3
Daftar Barang Ruangan. Example : At Ruang Satya Tirta verification at other area shown that recurrence
Teknik Pengairan; Lemari Kaca Besi for code 20701010, problem not found; therefore status can be closed
Computer set (Code 2120102001), Kursi (Code 2050201003). out.
Minor NC Closed In Quality Objective, target should be result oriented. For RAZ (9 May 12) : Corrective action was taken, BAPSI/Quality Objective 19 Oct 11 1110SHS03 5.4.1
example, Pelaksanaan Survey Lapangan, the target stated verification at other area shown that recurrence
220 days. From discussion shown, the real target was problem not found; therefore status can be closed
accomplishment for specific Survey Lapangan on time. out.

1 2 3 4 5 6 7 8
Minor NC Closed Laboratory Kimia & Fisika: RAZ (9 May 12) : Corrective action was taken, F.MIPA 14 Oct 11 0007JKALSD 7.6
1. All equipment & Measuring tools were not listed and verification at other area shown that recurrence (Kimia, Fisika, Biology) 01
monitored consistency. Measuring equipment could be problem not found; therefore status can be closed
planned for calibration or verification retention. out.
2. Label identification was not clear for all bottle, material,
Sample test, etc.
3. Environment was not kept clean and un-used material was
placed with not properly
Laboratory(Green House) Biology:

1. Label identification was not clear for sample name, status,
and expire date.
2. Environment was not kept clean and un-used material was
placed with not properly.
Minor NC Closed Method for Control and Identification of records Retention was Verification : - F.MIPA 28 Jun 11 0006JKALSD 4.2.4
not determined. Clausal 4.2.4). 11 Oct 11 (LS): - PWK (FT) 09
Fak. MIPA Jurusan. Biologi was not - BAK
implemented well (OPEN)
Fak. MIPA Jurusan Fisika Prodii-S2 was
not implemented well (OPEN)
Fak. Teknik Jurusan PWK was not
implemented well (OPEN).
BAK Sub Bag Anggaran & Pendapatan
Negara: Retention of records were
determined, however system/method for
disposition if records was not determined
yet (OPEN)
RAZ (9 May 12) : Verification at other area shown
that record retention was determined. Status can
be closed out.

1 2 3 4 5 6 7 8
Minor NC Open Management review was conducted; however the agenda (RAZ / 9 May 12): Corrective action taken but Management Review 14 Oct 1410_ANZ_001 5.6
of management review was not referring completely to still not effective to remove the problem. 2011
clause 5.6 ISO 9001:2008. Recurrence NC observed at other place. See
See minute of meeting generated from Management review finding no 0503JKAANZ_01
of BAU, Agriculture, Budidaya pertanian, Soil Dept, Sosek.

1 2 3 4 5 6 7 8
NC Minor New Agenda of Management Review in several areas was not Management review 3 May 2012 0503JKAANZ_ 5.6
referred to clausal 5.6 ISO 9001:2008. 01
There was no review for customer feedback (psikologi and
hubungan international) and internal audit (hubungan
internasional).
See FIB, BAAK, FH, TIK. Fisip
NC Minor New Survey Kepuasan Pelanggan in BAAK, FIA and BAK was Customer survey 3 May 2012 0503JKAANZ_ 7.2.3
not completed yet. 02
NC Minor New Internal Audit by PJM and Management Review were not Internal audit 5 May 0505JKAAN 5.6
conducted in BAK. 2012 Z_03
NC Minor New Sasaran mutu in Quality Manual Should be reviewed BAK 5 May 0505JKAAN 5.4.1
referred to new organization in BAK. 2012 Z_04

10. Assessment schedule
Management system elements to be assessed at each visit: Scheme specific elements:
Management review Corrective action Customer feedback and complaints
Management of change Preventive action and system planning Legal compliance
Continual improvement Use of LRQA logo and other marks Communications
Internal audit Prevention of pollution
Certificate renewal
Surveillance 1
Surveillance 2
Surveillance 3
Surveillance 4
Surveillance 5
Stage 1
Stage 2
Visit type >
April April April
Due date > Oct 2011
2012
Oct 2012
2013
Oct 2013
2014
Oct 2014
Start date > June

TBA TBA TBA TBA TBA TBA TBA
End date > 2011
Assessor days > 10 33 MD 12 12 12 12 12

Process / aspect
Final selection will be determined after review of management elements and actual performance
Management (Rector and all

relevant staff)
Teaching learning at Faculty and
Dept, including laboratory.
Supporting Processes
Next visit details

Visit type SV 1
Assessor days 12 MD Due date April 2012 Actual start / end dates TBA
Locations Universitas Brawijaya - Jl. Veteran Malang, Malang - JawaTimur
Activity codes 8020
Team TBA
Criteria ISO 9001:2008
Remarks and instructions
Note : Travelling from Surabaya to Malang may take 2 Hours.
Form: MSBS43014/0.2 0406 Report: / - 06 June 2012

11. Continual improvement tracking log ([ISO9001:2008], [Malang])
Baseline information
1. Improvement objective reference number: CI_1110_RAZ01 Date first recorded: Oct 11
5.Target
2. What is to be improved? 3. Baseline performance 4. Target performance
completion date
Running of E complaint NA Go live 2012
Progress information
9. Findings log
6. Visit type
7. Progress summary 8. Current performance cross reference 10. Status
and date
(if applicable)
Sv 1/May 12 On progress Go live at certain faculty NA continue
1. Reference number (CI-yymm-##) 6. Visit type/date (yymm) 10. Status open or closed
Form: MSBSF43018/0.2 - 0406 Report / Page 39 of 40

12. Visit theme selection
Visit type: Sv1
Due date (yy-mm): May 12 Location: Malang
Actual date: 9-12 May 12 Team: RAZ, SHS, ANZ, DGX
Duration: 12 MD
Selected theme(s)
Processes
(include reasons for theme selection)
Biz process compliance assessment See attached schedule
Form: MSBSF43010 revision 0, 0407 Report: / - 06/06/2012 Page 40 of 40

1st Surveillance ISO 9001 Report For UB

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1st Surveillance ISO 9001 Report For UB

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1st Surveillance

LRQA reference: JKT 6003728/ 0008

1. Executive report ........................................................................................................ 3

This report was presented to and accepted by:

Name: Mr. Prof. Dr. Ir. Yogi Sugito

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 2 of 40

Areas for management attention:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 3 of 40

Assessor: Rusli Ananda (Assessor-ID:04946),

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 4 of 40

Audit trails and sources of evidence:

Animal husbandry faculty

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 5 of 40

Audit trails and sources of evidence:

Evaluation and conclusions:

Audit trails and sources of evidence:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 6 of 40

Guide: Mrs. Endang

Laporan kegiatan Penerimaan mahasiswa have been reported and updated.

NC Minor was raised in BAAK (please see finding log).

Required Correction was raised in BAAK as follow:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 7 of 40

Internal Audit and Management Review were conducted and reported.

RENSTRA of Fakultas Ilmu Budaya was established and impplemented.

Required Corrections were raised in Fakultas Ilmu Budaya as follow:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 8 of 40

Guide: Mr. Ahmad Witjaksono;

NC Minor Was raised in Fakultas Hukum (Please see finding log).

Required Correction/RC was raised in Fakultas Hukum as follow:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 9 of 40

Guide: Mr. Tunggul Son Haji

Evaluation and conclusions:

Required Correction/RC were raised as follow:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 10 of 40

Guide: Mr. Tunggul Son Haji

Evaluation and conclusions:

Notes for improvement were raised as follow:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 11 of 40

Evaluation and conclusions:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 12 of 40

Audit trails and sources of evidence:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 13 of 40

Audit trails and sources of evidence:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 14 of 40

Audit trails and sources of evidence:

Assessor: Dede Gunawan (ID 04315)

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 15 of 40

Evaluation and conclusions:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 16 of 40

Ilmu dan Teknologi Pangan (S1) and (S2)

Keteknikan Pertanian Pangan (S1)

Teknologi Industri Pertanian

Teknologi Industri Pertanian (S2)

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 17 of 40

Audit trails and sources of evidence:

Evaluation and conclusions:

However some required correction were noted as follow:

Its recommended provided that a pharmacist as pharmacy PICs as per regulation

Expired Date of Codein was not defined yet

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 18 of 40

Audit trails and sources of evidence:

Audit trails and sources of evidence:

Form: MSBSF43000/1.1 - 0506 Report: / - 6-Jun-12 Page 19 of 40