NASA Procedural Requirements

NPR 1800.1E Effective Date: March 16, 2023 Expiration Date: March 16, 2028

Subject: NASA Occupational Health Program Procedures

Responsible Office: Office of the Chief Health & Medical Officer

Chapter 7. Occupational Health Review Process

7.1 General

7.1.1 This chapter establishes criteria for performing and documenting the results of, and delineating the requirements for:

a. Agency triennial OH reviews conducted at Centers to the extent required in their contract.

b. Center annual OH reviews conducted by Centers to the extent required in their contract.

c. Agency ad hoc reviews conducted at Centers to the extent required in their contract when a triennial OH review finds serious concerns and/or weaknesses that have not been addressed.

7.2 Responsibilities

7.2.1 The OCHMO shall:

a. Conduct Agency OH reviews to ensure adequate programs are implemented at the Centers to protect and promote workforce health, improve employees’ capabilities and abilities, and ensure the maintenance of safe and healthy working environments.

b. Define OH requirements as mandatory elements for programs or functions. Requirements include NPDs, NPRs, and external Federal, state, and local regulations, and consensus standards applicable to NASA.

7.2.2 Centers shall conduct annual OH reviews to ensure maintenance of program quality. During the year the Agency triennial OH review occurs, the Center annual OH review will be combined with the Agency triennial review.

7.3 Requirements Related to Triennial Occupational Health Reviews and Center Annual Occupational Health Reviews

7.3.1 The OCHMO OH review team and Center annual OH review teams shall:

a. Compare Center policies, procedures, and practices to OH requirements, as defined in this document, for all triennial OH reviews and Center annual OH reviews.

b. Assess the efficacy of the following OH programs:

(1) Medical care provided at each clinic (including emergency care capability and coordination with other departments, medical quality assurance, health clinic environment of care, childcare facility health aspects, preventive health and wellness activities, and aerospace medicine).

(2) EAP programs.

(3) 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 will be reviewed triennially but on a limited basis with written recommendations for improvements (if any) provided to the appropriate component facility management and stakeholders.

(4) IH programs.

(5) HP and radiation safety programs.

(6) FS programs.

(7) Health IT aspects of OM and IH.

(8) OM and FS aspects when childcare centers exist onsite.

7.3.2 The OCHMO OH review team shall assess FWC program case management:

a. At the NSSC whenever an onsite OH review is conducted at the Stennis Space Center.

b. At JSC whenever an onsite OH review is conducted at JSC.

7.3.3 The OCHMO shall:

a. Use qualified triennial OH review and Center annual OH review team members to conduct reviews in their respective program areas. See NPD 1210.2, NASA Surveys, Audits, and Reviews Policy.

b. Retain triennial OH review and Center annual OH review working documents, reports, and other information and data on file or in the Agency EHRS in accordance with NPR 1441.1 and this document.

7.3.4 The triennial OH review team shall categorize findings 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, the practice is still worthy of acknowledgement.

c. Opportunity for Improvement (OFI): A condition that could or should be improved. OFIs are accompanied by recommendations in the written report. Recommendations are not required to have Corrective Action Plans (CAP) in the System for Tracking Audits/Assessments and Reviews (STAR) unless specifically requested by the OH review team lead.

d. Other Finding of Significance (OFS): A finding that does not meet all the requirements and needs minor improvements. These findings require a CAP and subsequent status reports in STAR are required.

e. Nonconformance (NC): A divergence from a requirement (e.g., Federal, state, local, Agency, and Center) or an applicable consensus standard (e.g., ANSI and NIOSH) that may cause undue risk. These findings require Center response in the form of a CAP in STAR, along with follow-on status reports in STAR.

f. Observation: A neutral (non-positive and non-negative), informational comment to the Center.

Note: Requirements for submittal of CAPs to STAR are summarized in Table 7-1, Requirements for Submittal of CAP to STAR.

7.3.5 OH staff shall:

a. Conduct Center annual OH reviews during the two intervening years between triennial OH reviews to assess the effectiveness of OH program efficacy at their Centers encompassing the same disciplines as covered in the triennial OH reviews.

b. Categorize Center annual OH review findings as follows:

(1) OFI: Any deficiency noted during the annual OH review regardless of severity. For Center annual OH reviews, OFIs are required to have CAPs in the STAR.

(2) Observation: A neutral (non-positive and non-negative), informational comment relating to the discipline reviewed. All discipline specific questionnaires are required to be uploaded as an observational finding for the specific OH discipline.

7.3.6 Centers shall submit a CAP in STAR per Table 7-1.

7.3.7 Centers shall suitably address OFIs, from triennial OH reviews and Center annual OH reviews, within their internal action processes.

7.4 Triennial Occupational Health Reviews

7.4.1 The OCHMO shall:

a. Provide a forum, the triennial OH review, for Center/facility employees and the Agency OH review team to discuss OH-related issues.

Table 7-1. Requirements to Submittal of CAP to STAR

Table 7-2. Timeline and Requirements for the Triennial OH Review Process

7.4.2 The triennial OH review team shall:

a. Conduct triennial OH reviews of Centers to (1) identify and mitigate health risk, (2) ensure provision of consistent, high-level healthcare, (3) identify best practices and innovative solutions that provide greater operational effectiveness and efficiency, and (4) assess the adequacy of resources commensurate with the Center's size, population, and mission.

b. Schedule periodic reviews in advance. Every attempt will be made to conduct reviews during the same month at each respective Center during the target year.

c. Include a triennial OH review 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 is specified in the letter to the Center Director after coordination with the POC.

d. Provide out-briefing slides to the Center at the time of the senior management out-briefing.

e. Present an out-briefing to the Center Director or their senior management representative in a verbal, executive summary format for each discipline with discipline-specific slides summarizing the findings.

f. Prepare a final report based on the review findings which includes a cover letter, an executive summary, and detailed individual findings and a reiteration of the issues expressed in the Center senior management out-briefing and details of all review findings.

g. Address situations found during the triennial OH review that are IDLH by (1) immediately reporting the matter to an onsite Center representative directly (if present), by phone, or other means, (2) reporting the matter to the Agency review team leader and Center team leader as soon as practicable, and (3) delaying the review until the issue has been resolved and the condition is no longer IDLH.

7.4.3 Center Directors shall:

a. Provide adequate provisions and resources in support of a triennial OH review. This includes:

(1) Providing requested documentation and information by the deadline requested and in an orderly arrangement, utilizing any OCHMO specified templates, forms, or questionnaires.

(2) Providing onsite office and meeting room accommodations.

(3) Providing information technology support.

(4) Providing a status of the OH programs at in-briefings.

(5) Identifying discipline specific POCs.

(6) Being present for and supporting the onsite review activities.

(7) Responding with CAs to review findings by the requested deadline.

b. Appoint a Center primary POC for OH reviews, with enough authority and OH knowledge, to coordinate triennial OH reviews with the Agency OH review lead and provide ready access to facilities and other logistical support.

c. Ensure adequate and professionally appropriate technical POCs are available from each OH program to participate in the triennial OH review for the entire review period.

d. Provide for a management representative, familiar with Center OH operations, to attend the triennial OH review in-briefing, or specify an alternate, that is familiar with Center OH operations, if they are unavailable.

e. Provide for a senior management representative to attend the triennial OH review out-briefing or specify an alternate if unavailable.

f. Ensure CAPs for all nonconformance findings are developed and input into the STAR according to Table 7-1.

g. Ensure all CAs are resolved.

7.4.4 The Center-designated primary POC for the triennial OH review shall:

a. Provide a discipline specific POC list, including names, mail and e-mail addresses, and phone numbers at or before the designated due date.

b. Download (from the Agency OH website) and distribute the OH discipline-specific questionnaires and request for documents to the discipline-specific POCs and other appropriate Center OH representatives.

c. Review the Center-completed questionnaires to ensure answers to questionnaires are inclusive and representative of all Center contractor and NASA activities prior to returning them to the triennial OH review team.

d. Compile all requested information in the designated electronic file folder format specified in the e-mail sent to the POC in accordance with the timeline in Table 7-1

e. Submit questionnaires to the triennial OH review team lead, review team members, and others by Sharepoint (internal) or Box (external), at or before the due date, as specified in the pre-review document request e-mail.

f. Concurrently with submitting the questionnaires and documents requested, provide the triennial OH review team with (1) a list of the technical Center POC's for each OH discipline, (2) Center security requirements, (3) in-briefing and out-briefing locations, including building numbers and/or names, and room numbers, and (4) other logistical information as needed for the triennial OH review.

g. Provide and coordinate support requirements as noted on the request for support document.

h. Use STAR to enter CAPs and other pertinent review information.

i. Track CAs to closure in STAR.

7.4.5 Center discipline specific POCs shall:

a. Be available during all parts of the review for their triennial OH review team counterparts.

b. Coordinate and exchange OH discipline information with the appropriate triennial OH review team counterpart.

c. Provide objective evidence (e.g., documentation, all necessary records, and licenses) as requested.

d. Report real-time issues, problems, and findings status to their Center primary POC, as they arise, during the review process.

e. Escort triennial OH review team employees.

f. Coordinate and verify with their discipline specific Agency OH review team counterparts all specific discipline findings during the informal out-briefing.

g. Support the development of CAPs for each nonconformances and other findings of significance.

h. Represent their Center at the triennial OH review in-briefing, informal out-briefings, and senior management formal out-briefing.

7.5 Center Annual Occupational Health Reviews

7.5.1 Centers shall:

a. Ensure Center annual OH reviews are comparable to triennial OH reviews in breadth, quality, and efficacy.

b. Perform Center annual OH reviews during years when triennial OH reviews are not performed.

c. Follow the provisions of section 7.3 during Center annual OH reviews.

d. Ensure CAPs for all opportunities for improvement are developed and submitted into STAR.

e. Complete Center annual OH reviews by discipline and submit findings with supporting documentation into STAR, per the schedule in Table 7-3, Timeline and Requirements for Center Annual OH Reviews.

Table 7-3. Timeline and Requirements for Center Annual OH Reviews

f. Ensure their Center annual OH review findings are communicated to their Center Director and appropriate senior managers.

g. Submit all annual OH review reports into STAR as directed in the instructions found on the Agency OH website and consist of (1) a completed discipline-specific annual OH review questionnaire for each discipline and (2) any needed improvements noted during the Center annual OH review.

h. Use the most current OH review templates and instructions, which are provided on the Agency OH website to conduct Center annual OH reviews.

7.5.2 The non-submittal of an annual OH review from the Center will be reflected in the Center's subsequent triennial OH Review detailed report and if the trend continues, referred to the CHMO for decision on further action.

7.6 Center Ad Hoc Visits

7.6.1 General

7.6.1.1 Center ad hoc visits by OCHMO are conducted outside of the regular triennial OH review cycle because of serious concerns and weaknesses identified that have not been addressed or have taken an inordinate amount of time to correct.

7.6.1.2 Center ad hoc visits do not reset the timeline for triennial OH reviews.

7.6.2 Responsibilities

7.6.2.1 The OCHMO shall:

a. Send a letter to the triennial OH review POC two months prior to the ad hoc visit with specifics on what OCHMO will be reviewing.

b. Send an announcement letter to the Center Director one month prior to the ad hoc visit.

c. Update the existing Center OH review program already created in STAR from the triennial OH review, outlining the status of the deficiency, rather than creating a new Center triennial OH review program for Center ad hoc visit. This status update will be input into the Finding Narrative field for each NC, OFS, and OFI (as determined by auditor) finding.

7.6.2.2 The OCHMO OH review team shall conduct an ad hoc visit of a Center, per Table 7-4, Table and Requirements for Center Ad Hoc Visits, as dictated by the OH risk determined from the triennial OH review findings. All ad hoc visits will be scheduled within the year following the triennial OH review and focus on NCs and OFS noted during the triennial OH review. OFIs may also be focused on as determined by the auditor.

7.6.2.3 Subsequent to the in-briefing, the OCHMO OH review team will review documentation and visit the areas with the NCs, OFSs, and if applicable, OFIs to verify findings from the triennial OH review have been properly addressed

7.6.2.4 Centers shall:

a. Provide a status of the NCs and OFSs found at the last triennial OH review at an in-briefing presentation. During the in-briefing, Centers should be prepared to answer any questions OCHMO has to better understand the status of each finding and discuss any problems and issues the Center may be experiencing in addressing the deficiencies, adopting CAPs, and closing out the findings.

b. Enter updated CAPs into STAR within six months after a revisit for each nonconformance and other finding of significance reviewed during the ad hoc visit only if a CAP was not initially submitted after the triennial OH review.

Table 7-4. Timeline and Requirements for Center Ad Hoc Visits

DISTRIBUTION:
NODIS

This document does not bind the public, except as authorized by law or as incorporated into a contract. This document is uncontrolled when printed. Check the NASA Online Directives Information System (NODIS) Library to verify that this is the correct version before use: https://nodis3.gsfc.nasa.gov.