Effective Date: October 06, 2009
Expiration Date: December 06, 2015
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7.1.1 The NASA Office of the Chief Health and Medical Officer (OCHMO) conducts Occupational Health (OH) reviews and defines OH "requirements" as mandatory elements for programs or functions. Requirements include NASA Policy Directives (NPDs), NASA Procedures and Requirements (NPRs) and external regulations and consensus standards applicable to NASA. This chapter establishes a method for performing and documenting the results of, and delineating the requirements for, Agency OH reviews conducted at NASA Centers/Facilities (hereinafter Centers), including NASA Headquarters (HQ) and NASA's Jet Propulsion Laboratory to the extent required in their contract.
7.1.2 The goal of the OCHMO is to ensure the protection and promotion of NASA workforce health, to improve workers' capabilities and abilities, and to ensure the maintenance of their safe and healthy working environment. Regular reviews of OH components are required to accomplish this goal, which includes verification of compliance with other Federal, state, local, and Center regulations. OH reviews help identify and mitigate risk, provide a consistent, high level of health care, and identify best practices and innovative solutions that provide greater operational effectiveness and efficiency. Achieving and maintaining sufficient resources commensurate with the Center's size, population, and mission are within the scope of OH reviews.
7.1.3 OH reviews provide a forum for NASA Center/Facility personnel and OCHMO to discuss OH-related issues for which OCHMO may be able to assist. The OCHMO OH Review Team members are advocates and provide technical help; guidance on best practices; support for Agency OH initiatives; facilitation of specialized training for emerging health threats and new requirements; and enhancement of the competency of OH employees.
7.1.4 Periodic OH program reviews shall include assessment of medical care provided at each Center's Occupational Medicine Clinic (including emergency care capability and coordination with other departments, medical quality assurance, health clinic environment of care, and childcare facility health aspects); preventive health and wellness activities; Employee Assistance Programs; Federal Workers' Compensation; fitness facilities; industrial hygiene; health physics; and food safety.
7.1.5 OCHMO Review Team Members shall be qualified to conduct review in their specific program area per NPD 1210.2, NASA Surveys, Audits, and Reviews Policy, paragraph 5 (2).
7.1.6 Each member of the OCHMO Review Team shall:
a. Maintain the standards and ethics expected of a NASA civil service or contractor employees;
b. Always act in the interest of the health and safety of workers;
c. Base judgments on scientific knowledge and technical competence, seeking specialized expert advice when necessary;
d. Refrain from any judgment, advice, or activities that may endanger the trust in their integrity or impartiality;
e. Maintain full professional independence;
f. Observe confidentiality in performing duties;
g. Treat coworkers and other individuals equitably and without any form of discrimination in accordance with NPR 2081.1, Nondiscrimination in Federally Assisted and Conducted Programs;
h. Establish and maintain clear channels of communication among the team members, OCHMO management, Center points of contact, Center management, and others;
i. Maintain high-quality review records, with the appropriate degree of confidentiality, for identifying OH findings at Centers; and
j. Provide objective evidence including, but not limited to, surveillance of working environments, personnel interviews, documentation and records, and verification of personnel certifications.
7.1.7 Appendix E contains the current Center review schedule. Due to the potential for change to accommodate coordination with the OSMA and environmental review schedules, the latest schedule of Center reviews shall be maintained on the OH Web site at www.ohp.nasa.gov.
7.2.1 The Chief Health and Medical Officer (CHMO) shall be responsible for:
a. Ensuring that planned program reviews of NASA facilities are conducted;
b. Determining the value and adequacy of Center OH programs; and
c. Determining if Centers are providing adequate OH program resources.
7.2.2 The Director of Occupational Health shall be responsible for:
a. Assuring overall occupational health review process efficacy;
b. Appointing the team lead for Center reviews; and
c. Reviewing and approving occupational health review reports.
7.2.3 The OH Review Team Leader shall be the Agency's primary representative for the review process and shall be responsible for:
a. Implementing overall, the Agency's occupational health review process, including pre and post review aspects, real-time problem coordination and resolution, and briefing presentations;
b. Initiating contact with each Center prior to review;
c. Coordinating and exchanging information with each Center primary Point of Contact (POC);
d. Establishing each Center's review schedule and associated meetings;
e. Consulting with the Agency's Director of Occupational Health, as needed during the review, regarding nonconformance findings;
f. Providing the Center POC or Contracting Officer's Technical Representative (COTR) with a listing of nonconformance findings; and
g. Continually improving the occupational health review process.
7.2.4 Center Directors shall be responsible for the following:
a. Appointing a Center POC, with sufficient authority and OH knowledge to coordinate Center onsite reviews with the OCHMO, and to provide ready access to facilities and other logistical support;
b. Providing the review effort with adequate resources and personnel;
c. Attending the out-briefing or designating an alternate if he/she is unavailable;
d. Assuring the corrective action plan addresses all nonconformance findings;
e. Providing a corrective action plan to the OCHMO;
f. Providing adequate resources to resolve corrective actions;
g. Ensuring implementation of the requests for actions designated in the review; and
h. Notifying the OCHMO; Office of Safety and Mission Assurance's Safety Assurance Requirements Division, and OH Director of other Center reviews, audits, or visits from outside regulatory bodies, such as the Occupational Safety and Health Administration, the Nuclear Regulatory Commission (NRC), or state or local government organizations.
7.2.5 The Center primary POC shall be responsible for the following:
a. Coordinating and exchanging information with the OCHMO Team Leader:
(1) Providing a discipline-specific POC list to the OCHMO Review Team Leader, including names, mail and e-mail addresses, and phone numbers.
(2) Distributing review questionnaires from the Review Team Leader to Center personnel.
(3) Providing completed questionnaires and requested documentation to the Review Team Leader on time and in a concise electronic format.
b. Providing and coordinating support requirements:
(1) Arranging for badges and escort of the review team, where needed.
(2) Coordinating property and set up requirements for equipment use (e.g., laptop PCs, cameras, PDAs, wireless Internet access, etc.).
(3) Arranging for a private work area and a private interview room for the Agency Review Team.
(4) Arranging rooms and meeting announcements for in-briefings and out-briefings.
c. Supporting the onsite review:
(1) Supporting the in-briefing, out-briefing, and finding coordination meetings.
(2) Providing access to Center internal locations subject to the scope of the review.
(3) Providing onsite access to additional Center documentation, as needed.
(4) Providing wireless remote Internet access.
(5) Coordinating real-time issues and problems, as they arise, during the review process.
d. Providing postreview support:
(1) Coordinating nonconformance findings with Center Management, as needed.
(2) Overseeing preparation of the corrective action plan.
(3) Tracking Centers' nonconformance findings to closure.
7.2.6 Center discipline-specific points of contact shall be responsible for:
a. Being available during all parts of the review for their Agency Review Team counterparts;
b. Coordinating and exchanging OH discipline information with the appropriate OCHMO Review Team counterpart;
c. Supporting the review in-briefing and finding coordination briefings;
d. Providing objective evidence (e.g., documentation, all necessary records, licenses, etc.) as requested;
e. Escorting Agency Review Team personnel;
f. Reporting real-time issues and problems to the Center primary POC, as they arise, during the review process;
g. Coordinating and verifying with the Agency Review Team all specific discipline findings prior to the finding coordination meeting; and
h. Representing the Center at the finding coordination meetings, as applicable.
7.2.7 Mandatory requirements and responsibilities or individual OCHMO Review Team members and the OCHMO Secretary/Administrative Assistant to the OH Director are located in Appendix C.
7.3.1 OH reviews shall be performed in accordance with the requirements of NPD 1210.2, NASA Surveys, Audits, and Reviews Policy, and shall compare NASA Center policies, procedures, and practices to (1) regulatory and other compliance requirements, (2) NASA Agency policy requirements, and (3) consensus standards.
7.3.2 A written report and program rating shall be prepared by OCHMO based on the OH review findings. The report and rating shall be provided to each Center, with a copy to the appropriate Mission Associate Administrator, Institutional Corporate Management, and Safety and Mission Assurance Directorates.
7.3.3 Centers are responsible for tracking and closing all nonconformance findings.
7.3.4 Table 1 provides the tasks and associated timelines for the OH review process.
|1||Memo to Center Directors with annual OH review schedule for upcoming year||By November 1 of the previous year||OCHMO|
|2||Electronic communication to Center COTR(s); provision of OH review questionnaires and a request for documents for OCHMO review||Approximately 60 days before OH review visit is scheduled to take place at the Center||OCHMO|
|3||Memo to Center Director announcing OCHMO's upcoming OH review||Approximately 30 days before OH review visit is scheduled to take place at the Center||OCHMO|
|4||Center-completed OH review questionnaires, requested documents, and discipline-specific POC information provided to OCHMO||30 days or more before OH review takes place or by the due date indicated in OCHMO's previous communication||Center POC/COTR|
|5||Written list of nonconformance findings provided to Center review POC/COTR||OH Review Formal Out brief||OCHMO|
|6||Memo and report to Center Director with the results of the OH review and a rating of the OH programs||Approximately 60 days after the last day of the OH review||OCHMO|
|7||Off-year OH self-reviews with supporting documentation, and status of previous nonconformance findings||During the off-years in the same month as the last onsite OCHMO occupational health review||Center Director|
22.214.171.124 Task 1: OH reviews are conducted, by either OCHMO or the Center, annually and are set by the OCHMO, and are conducted (to the extent possible) during the same month at each respective Center. Also see Paragraph 7.1.8.
126.96.36.199 Task 2: Each Center COTR shall distribute the OH discipline-specific questionnaires and request for documents to the appropriate Centers' OH representatives. The Centers' OH representatives shall provide completed questionnaires and/or the documents requested by OCHMO to their COTR or other Center designated POC. The COTR or other Center-designated primary POC shall review the questionnaires, determine their viability, and return the questionnaires to the OCHMO Review Team Leader. Concurrently, or before the submittal of documents to OCHMO, the Center COTR or other designated POC shall also provide OCHMO with a list of OH disciplines technical POC's, Center security requirements and badging, in-brief and out-brief locations and any other logistical information needed for the OH review. All information shall be provided via e-mail or other electronic method, where feasible.
188.8.131.52 Task 3: A memo shall be sent from OCHMO to the Center Director to announce the upcoming OH review, including copies to the Center's Associate Administrator, Institutional Corporate Management, and Safety and Mission Assurance Directorates. The memo to the Center Director shall include OCHMO's detailed report of the OH review findings, including details about recurring nonconformances.
184.108.40.206 Task 4: Centers shall provide comprehensive answers to questions on questionnaire; documentation, discipline-specific POC's information, and other requested information in a concise and well organized electronic format. Questionnaires shall be in electronic format and inclusive and representative of all Center contractor and NASA activity under each OH discipline-specific questionnaire.
220.127.116.11 Task 5: A written listing of all nonconformance findings shall be provided to the Center POC or COTR at or before the out-briefing to Center management, in accordance with NPD 1210.2, NASA Surveys, Audits, and Reviews Policy.
18.104.22.168 Task 6: A memo, executive summary and comprehensive report containing the results of the review shall be provided to the Center Director.
22.214.171.124 Task 7: During years when an OCHMO-led review is not conducted at a Center, the Center shall perform an OH self-review during the same month of the regularly scheduled OCHMO onsite review and submit the review findings to the OCHMO Review Team Leader. The minimum elements of the self-review shall include: overall or general account of what was physically evaluated in each OH discipline are reviewed, names and qualifications of Center individual(s) conducting the reviews, dates and locations of each program or area reviewed, verification of compliance with other Federal, state, local, and Center regulations, a status and assessment of the previous OCHMO findings, and a corrective action plan for the nonconformance findings from the self-review. The Center report shall also describe any substantial improvement and/or degradation in each OH Program area. The Center self-review team members shall be qualified to conduct reviews in their specific program area per NPD 1210.2, NASA Surveys, Audits, and Reviews Policy, paragraph 5 (2).
7.3.5 The nonsubmittal of an OH self-review from the Center during an off-year shall be referred to the CHMO for decision on further action and reflected in the Center's subsequent onsite OH review detailed report.
7.3.6 Onsite OH Reviews
126.96.36.199 The OH review shall include an in-briefing, including introductions, the scope of the review, explanation of the mechanisms and review results, and coordination of other necessary details. The Center component of the in-briefing shall include introductions, a statement of open findings from previous reviews, and a summary of significant Center aspects affecting OH Programs since the last on-site OCHMO review. Those in attendance shall include at least one senior management representative with responsibility and authority over Center OH Programs.
188.8.131.52 The Center shall provide multidisciplinary coverage for the entire review period. The in-brief shall provide a forum for exchange of questions, information, and details regarding the review. It shall be an opportunity for the OH Review Team to offer expert information and advocacy, and to provide an opportunity for Center feedback on OH review process improvements. The Center shall present their top OH concerns and a status of any open or unresolved nonconformance findings from previous OH reviews.
184.108.40.206 Each OCHMO Team member shall coordinate with their OH discipline counterpart to confirm or clarify details of their parts of the review, discuss Center OH programs and processes, and plan area visits. OCHMO Review Team members shall collect pertinent objective evidence of their findings including, but not limited to, documentation and verification of facts through interviews, tours of work areas, observation of activities and the surrounding work environment and conditions, record reviews, and documentation accessibility and availability. Centers shall make all necessary records available to the OCHMO Review Team for review and assessment.
220.127.116.11 Center Directors shall ensure that adequate and professionally appropriate technical points of contact for each OH program are available and can participate in the OH review.
18.104.22.168 Immediately dangerous to life and health (IDLH) situations found during the OH review shall be addressed as follows:
22.214.171.124 The issues shall be immediately reported to the onsite Center supervisor responsible for the area. Subsequently, it shall be immediately reported to the OCHMO Review Team Leader and Center Team Leader. The OHMO reviewer shall not commence the review until the issue has been resolved and the situation is no longer IDLH.
126.96.36.199 The Out-briefing shall be presented by the OCHMO Review Team to the Center Director or his or her representative in a verbal executive summary format. OCHMO's presentation shall focus on the strengths, weaknesses, and significant nonconformance findings. Any best practices found during the OH review shall also be highlighted. Per NPD 1210.2, a written list of nonconformance findings shall be provided by the OCHMO Review Team Leader to the Center COTR at or before the out briefing.
188.8.131.52 A detailed written report shall be provided to the Center within approximately 60 days of the Out-brief. The written review report shall be a reiteration of the issues expressed in the Center Out-brief, including details of all review findings. The Center shall have approximately 60 days after receipt of the written report to reply to the OCHMO Review Team Leader with a corrective action plan describing remedial actions for the nonconformance findings. Center corrective action plans shall be approved and signed by the Center Director, and shall follow the narrative format and numbering system of the original OCHMO report.
184.108.40.206 The Center shall keep the OCHMO Review Team Leader informed of the status of corrective action report if a delay is anticipated. Corrective actions shall only be "closed" when the anomalous condition associated with the nonconformance no longer exists.
220.127.116.11 Findings shall be categorized as follows:
a. Commendation: A practice that exceeds requirements or is a time or cost-saving measure, without sacrificing OH objectives or requirements;
b. Recognition: The acknowledgement of a significant improvement or progress toward required Center OH program requirements or other positive noteworthy accomplishment not attaining levels commensurate with those of a commendation;
c. Opportunity for Improvement: A condition that meets compliance requirements but could or should be improved. Opportunities for Improvement are accompanied by "Recommendations" in the written report. Recommendations are not required to be addressed in the Center's corrective action plan or subsequent status reports; and
d. Nonconformance: A divergence from a compliance requirement (Federal, state, local, NASA Agency, NASA Center, etc.) or an applicable consensus standard (the American National Standards Institute, the National Institute for Occupational Safety and Health, the Environmental Protection Agency, etc.). These findings require Center response in the corrective action plan and subsequent status reports.
18.104.22.168 Working documents, reports, and results shall be permanently retained on file or in the Agency Health Electronic Database for use and future examination, unless deemed otherwise by the Director of Occupational Health.
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