Effective Date: October 06, 2009
Expiration Date: June 06, 2023
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7.1.1 To fulfill its mission, the OCHMO defines OH "requirements" as mandatory elements for programs or functions. Periodic Agency Occupational Health (OH) reviews are conducted to ensure adequate programs are implemented at the Centers, and ultimately to protect and promote NASA workforce health, improve workers' capabilities and abilities, and ensure the maintenance of their safe and healthy working environment. Centers are required to conduct annual self-assessments to ensure maintenance of program quality during the two years between Agency OH review team onsite reviews.
7.1.2 Requirements include NASA Policy Directives (NPDs), NPRs, and external Federal, state, and local regulations and consensus standards applicable to NASA.
7.1.3 This chapter establishes:
a. Criteria for performing and documenting the results of, and delineating the requirements for, Agency periodic OH reviews conducted at all NASA Centers, including NASA Headquarters (HQ) and NASA's Jet Propulsion Laboratory to the extent required in their contract.
b. Criteria for performing and documenting the results of, and delineating the requirements for, Center annual OH reviews conducted at NASA Centers, including NASA HQ and NASA's Jet Propulsion Laboratory to the extent required in their contract.
7.2.1 All OH program reviews and self-reviews shall:
a. Identify and mitigate health risk;
b. Ensure provision of consistent, high-level health care;
c. Identify best practices and innovative solutions that provide greater operational effectiveness and efficiency;
d. Assess the adequacy of resources commensurate with the Center's size, population, and mission; and
e. Include assessment of:
(1) 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, childcare facility health aspects, and preventive health and wellness activities);
(2) Employee Assistance Programs;
(3) Federal Workers' Compensation Program Case Management (JSC & NSSC);
(4) Fitness Program and Facilities
NOTE: NASA component facility fitness clubs or similar exercise clubs that utilize equipment and/or other accessories within NASA-maintained interior space shall be reviewed triennially but on a limited basis with written recommendations for improvements (if any) provided to the appropriate component facility management and stakeholders.
(5) Industrial Hygiene Programs;
(6) Health Physics and Radiation Safety Programs; and
(7) Food Safety Programs.
7.2.2 OH review and self-review team members shall be qualified to conduct reviews in their respective program areas per NPD 1210.2, NASA Surveys, Audits, and Reviews Policy.
7.2.3 All OH reviews and self-reviews shall compare NASA Center policies, procedures, and practices to OH requirements, as defined in this NPR.
7.2.4 All OH review and self-review findings shall be categorized as follows:
a. Commendation: A practice that exceeds requirements, is an Agency best practice, or is a time or cost-saving measure, that occurs without sacrificing OH objectives or requirements;
b. Recognition: The acknowledgement of a significant improvement or progress toward meeting Center OH program requirements or other positive noteworthy accomplishment. While not attaining levels commensurate with those of a commendation — it is still worthy of acknowledgement;
c. Opportunity for Improvement: A condition that could or should be improved. Opportunities for Improvement (OFI's) are accompanied by "Recommendations" in the written report. Recommendations are not "required" to have Corrective Action Plans (CAPs) in the Surveys, Audits, and Assessments Information System (SAARIS) unless specifically requested by the OH review team lead. Centers shall suitably address OFI's within their internal action processes;
d. Nonconformance: A divergence from a requirement (Federal, state, local, NASA Agency, NASA Center, etc.) or an applicable consensus standard (ANSI, NIOSH, etc.) that may cause undue risk. These findings require Center response in the form of a Corrective Action Plan in SAARIS, along with follow-on status reports in SAARIS; and
e. Observation: Observations can be external or internal. An External Observation is defined as a neutral (non-positive and non-negative), informational comment to the Center. An Internal Observation is defined as a reviewer comment, either for the record or to help the reviewer in future reviews.
7.2.5 All OH review and self-review working documents, reports, and other information and data shall be retained on file or in the Agency EHRS in accordance with NASA's record requirements and this NPR.
7.3.1 In addition to the provisions for reviews provided in section 7.2 of this chapter, Agency OH reviews shall:
a. Provide a forum for NASA Center/Facility personnel and OH review team to discuss OH-related issues; and
b. Provide advocacy for the Centers'/Facilities' occupational health disciplines by offering 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.
7.3.2 The latest review schedule shall be maintained on the Agency OH Web site.
NOTE: Additional responsibilities for Agency OH reviews are delineated in Table 1.
7.4.1 The CHMO shall ensure that periodic OH program reviews of NASA Centers are conducted, final OH reports are reviewed and approved, and results provided to Center Directors.
7.4.2 Centers shall:
a. Appoint a Center POC, with sufficient authority and OH knowledge, to coordinate Agency OH onsite reviews with the Agency OH review lead and provide ready access to facilities and other logistical support;
b. Ensure that adequate and professionally appropriate technical points of contact for each OH program are available to participate in the OH review for the entire review period;
c. Support the OH review team with adequate resources and personnel;
d. Provide comprehensive answers and relevant information on the discipline-specific questionnaires;
e. Make all pertinent records, documentation, and information available to the Agency OH Review Team for review and assessment in a timely manner;
f. Provide for a management representative, familiar with Center OH operations, to attend the Agency OH review in-briefing, or specify an alternate, that is familiar with Center OH operations, if he/she is unavailable;
g. Provide for a senior management representative to attend the Agency OH review out-briefing, or specify an alternate if he/she is unavailable;
h. Ensure that final OH self-review reports are reviewed and approved, and the results provided to Center Directors;
i. Ensure corrective action plans for all nonconformance findings are developed and entered into the SAARIS according to Table 1 specifications so OCHMO and the Center OH Office can validate remediation has been completed; and
j. Provide adequate resources to resolve corrective actions.
7.4.3 The Center POC shall be responsible for:
a. Coordinating and exchanging information with the Agency OH review team leader which includes:
(1) Providing a discipline-specific POC list, including names, mail and e-mail addresses, and phone numbers at or before the designated due date.
(2) Distributing review questionnaires to Center personnel.
(3) Validating and providing completed questionnaires and requested documentation at or before the due date, and in the designated electronic folder format.
b. Providing and coordinating support requirements as noted on the "request for support" document;
c. Using SAARIS to enter their Corrective Action Plans and other pertinent review information;
d. Tracking corrective actions to closure in SAARIS;
e. Downloading and distributing the OH discipline-specific questionnaires and request for documents to the appropriate Centers' OH representatives; and
f. Supporting the Agency OH review team.
7.4.4 Center discipline-specific points of contact shall be responsible for:
a. Being available during all parts of the review for their OH review team counterparts;
b. Coordinating and exchanging OH discipline information with the appropriate OH review team counterpart;
c. Providing objective evidence (e.g., documentation, all necessary records, licenses, etc.) as requested;
d. Reporting real-time issues, problems, and findings status to their Center POC, as they arise, during the review process;
e. Escorting Agency OH review team personnel;
f. Coordinating and verifying with their discipline specific Agency OH review team counterparts all specific discipline findings prior to the informal out-briefing;
g. Supporting the development of corrective action plans for each nonconformance finding; and
h. Representing their Center at the Agency OH review in-briefing, Agency OH informal out-briefings, and Agency OH senior management out-briefing.
7.5.1 In addition to the requirements of this section, Agency OH reviews shall follow the provisions of section 7.2 of this Chapter.
7.5.2 Agency-level OH reviews of NASA Centers are conducted by the Agency OH review team periodically.
7.5.3 Periodic reviews are scheduled in advance by the Agency OH review team and are conducted (to the greatest extent possible) during the same month at each respective Center during the target year.
7.5.4 Center POCs shall download (from the OHP Web site) and distribute the OH discipline-specific questionnaires and request for documents to the appropriate Centers' OH representatives, and support the OH review team.
7.5.5 Answers to questionnaires shall be all inclusive and representative of all Center contractor and NASA activities.
7.5.6 The Centers' POC shall review the Center-completed questionnaires and determine their viability, prior to returning them to the Agency OH review team.
7.5.7 Concurrently with submitting the questionnaires and documents requested, the Center POC shall also provide the Agency OH review team with:
a. A list of the technical Center POC's for each OH discipline;
b. Center security requirements;
c. In-brief and out-brief locations, including building numbers and/or names, and room numbers; and
d. Other logistical information as needed for the Agency OH review.
7.5.8. All requested information shall be compiled in the Agency OH review team file folder format specified in the e-mail sent to the POC in accordance with the timeline in Table 1.
7.5.9 The Agency OH review shall include an in-briefing as requested in the e-mail to the POC and in the letter to the Center Director. The in-briefing agenda and time shall be specified in the letter to the Center Director after coordination with the POC.
7.5.10 A written and/or electronic listing of all nonconformance findings will be provided to the Center at the time of the senior management out-briefing.
7.5.11 The out-briefing shall be presented by the Agency OH review team to the Center Director or his or her senior management representative in a verbal, executive summary format for each discipline.
7.5.12 A report shall be prepared by the Agency OH review team based on the review findings.
7.5.13 The report shall be a reiteration of the issues expressed in the Center senior management
out-briefing and shall additionally include details of all review findings.
7.5.14 The report shall consist of a cover letter, an executive summary with a table of findings by type of finding and functional category, and the detailed audit card findings.
7.5.15 Centers shall track and close all nonconformance findings using the SAARIS.
7.5.16 Centers shall not submit written CAP status updates to the Agency OH review team.
7.5.17 Table 1 summarizes the tasks and associated timelines and requirements for the Agency OH review process.
Timeline and Requirements 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||Agency OH review team|
|2||Electronic communication to Center POC with a request for documents for the Agency OH review
NOTE: Documents are available from the OHP Web site
|Approximately 120 days before the Agency OH review visit is scheduled to take place at the Center||Agency OH review team|
|3||Center-completes OH review, questionnaires, assembles requested documents, and discipline-specific POC information and provides them to the Agency OH review team||60 days or more before the Agency OH review takes place; or by the due date indicated in the Agency OH review team's previous communication||Center POC|
|4||Notification of the Center Director of the upcoming OH review||Approximately 30 days before Agency OH review visit is scheduled to take place at the Center||Agency OH review team|
|5||Listing of nonconformance findings is provided to the Center||Senior Management Out-brief||Agency OH review team|
|6||Memo and Executive Summary report sent to Center Director with the results of the OH review; An electronic copy with detailed audit card findings distributed electronically to Center Director, Center POC, the appropriate Mission Associate Administrator, Institutional Corporate Management, and Safety and Mission Assurance Directorates||Approximately 60 days after the last day of the Agency OH review||Agency OH review team|
|7||Corrective Action Plans for nonconformance findings due in SAARIS||6 months after the last day of the Agency OH review||Center POC|
|8||Review implementation status of CAPs||By the next triennial Agency OH review of the Center||Agency OH review team|
7.5.18 Immediately dangerous to life and health (IDLH) situations found by the Agency OH review team shall be addressed as follows:
a. The Agency OH review team member shall endeavor to keep personnel from exposure to any IDLH situation and shall immediately report the matter to an onsite Center representative directly (if present), by phone, or other means.
b. As soon as practicable, the Agency OH review team member shall report the matter to the Agency Review Team Leader and Center Team Leader.
c. The Agency reviewer shall not commence the review until the issue has been resolved and the condition is no longer IDLH.
7.6.1 Center self-reviews shall be comparable to Agency OH reviews in profundity, quality, and efficacy.
7.6.2 Centers shall perform annual Center OH self-reviews during years when Agency OH reviews are not performed.
7.6.3 In addition to the requirements of this paragraph, Center self-reviews shall follow the provisions of section 7.2 of this Chapter.
7.6.4 Centers shall ensure corrective action plans for all nonconformance findings are developed and entered into SAARIS.
7.6.5 Self-reviews may be conducted anytime, but results and products shall be completed and findings with supporting documentation entered into SAARIS, as per the requirements in Table 2, Timeline for Center Self-Reviews.
7.6.6 Centers shall prepare a written report based on their OH review findings for their Center Director and appropriate senior managers.
7.6.7 The report shall consist of a memo, executive summary, and detailed findings by functional categories.
7.6.8 Centers shall use the most current self-evaluation tools and instructions, which are provided on the Agency OHP Web site to conduct self-reviews.
7.6.9 Conducting a Center OH self-review shall include:
a. A self-assessment performed against the requirements of NPR 1800.1, using the Agency OH questionnaires as a guidance tool;
NOTE: Questionnaires may be found on the Agency OH Web site. If the Agency OH questionnaires are not used, the Center must use another questionnaire or appropriate tool to ensure all program elements are reviewed and provide to OCHMO upon request. Submission of completed questionnaires to OCHMO is not required.
b. A self-assessment performed on the Center's records and documents. Submission of the list of Center documents assessed as part of the self-review is required;
NOTE: This is based on the list of the "Request for Documents and Information" found on the OHP Web site. Submission of the actual records and documentation is not required.
c. An assessment and status update of any of the Center's open nonconformance findings from previous Agency OH reviews and/or Center OH self-reviews. Submission of the list and status of open nonconformance findings is required;
d. A list of individuals, by disciplines, who performed or were involved in the Center OH self- review. The listing shall include their professional qualifications relative to the self-review. Submission of the list of individuals and their qualifications is required;
e. A list of areas, by discipline, that were reviewed as part of the self-review. Submission of the list of areas reviewed is required;
f. A list of the individuals, by discipline, who were interviewed as part of the self-review. Submission of the list of individuals interviewed is required; and
g. Any substantial changes, positive or negative in each OH Program discipline. Submission of the substantial changes is required.
7.6.10 The non-submittal 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 Agency OH Review detailed report.
NOTE: Additional requirements for Center OH review teams are delineated in Table 2.
Table 2: Timeline and Requirements for Center Self-Reviews
|Conduct off-year OH self-reviews and record findings in SAARIS with supporting documentation and status of previous nonconformance findings||On or before December 31st of each year||Center OH POC|
|Annually submit information and send to the SEHO (or designee) in support of the Annual OSHA Report*||On or before December 31st of each year||Center OH and Safety POC|
*NOTE: Although not directly part of the OH review process, the additional information is closely related to Center self-reviews. Centers should consider doing self-reviews and information gathering in support of the Annual OSHA Report simultaneously.
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