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3620 –
ESH&Q Aspects of Self-Assessment |
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1.0
Introduction
Jefferson Lab has effectively integrated safety in the Lab’s management system, institutionalizing Environmental, Safety, Health, and Quality (ESH&Q) into line management and work practices at all levels, so that missions are accomplished while protecting the public, the worker, and the environment. An essential feedback on the adequacy of ESH&Q implementation is through Jefferson Lab’s Self-Assessment Program which requires line managers to identify and assess the ESH&Q aspects of their assigned mission and work.
2.0
Self-Assessment
Self-assessment at Jefferson Lab is accomplished by:
- Management Self-Assessment (MSA);
- Independent Assessment (IA);
- Performance Evaluation and Measurement Plan (PEMP) Report (includes self-assessment activity); and Individual Performance Evaluations.
All of these assessment activities address ESH&Q issues.
The MSA and IA procedures are documented at:
http://www.jlab.org/div_dept/dir_off/oa/assess.html
3.0
Responsibilities
Associate Directors
Associate Directors are responsible for determining the effectiveness of their organizational element’s performance. Management self assessments, which are conducted by the line organizations and approved by the cognizant Associate Director, are one element in meeting this responsibility.
Line Managers
Line managers perform Management Self-Assessments. The schedule for these assessments is approved annually by the Laboratory Director.
Quality Assurance and
Continuous Improvement Department
The Quality Assurance and Continuous Improvement Department (QA/CID) within the ESH&Q Division is responsible for coordinating the laboratory’s assessment program and providing independent assessment of laboratory performance.
The Self-Assessment and Quality Assurance (SA/QA) Group within the department develops assessment policies and procedures for approval by Director’s Council; facilitates implementation of these policies; conducts independent assessments; recommends improvement and corrective actions; tracks findings and commitments resulting from independent assessments and from lab-wide assessments through corrective action planning, execution, and closure; monitors corrective action effectiveness; and provides appropriate assessment information, advice, and training, when requested.
This department is also responsible for data trending and providing relevant feedback for continuous improvement.
4.0
Program
Management self-assessment (MSAs) of ESH&Q issues are scheduled annually and conducted by line management following a procedure documented at:
http://www.jlab.org/div_dept/dir_off/oa/assess.html
The QA/CID staff assist line management with these assessments. Deficiencies of sufficiently high significance and their corrective actions are tracked in the Laboratory’s corrective action tracking system (CATS).
Independent assessments (IAs), are also scheduled annually, but are performed by or under the direction of QA/CID. These assessments are intended to identify improvement opportunities and to provide management and staff with an independent overview of laboratory performance. Deficiencies of sufficiently high significance and their corrective actions are tracked in CATS.
The Laboratory’s procedure for ensuring effective tracking and closure of significant issues whether identified in MSAs, IAs, or other means is documented at:
http://www.jlab.org/div_dept/dir_off/oa/issues.html.
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ISSUING
AUTHORITY |
CHAPTER
AUTHOR |
APPROVAL
DATE |
EFFECTIVE
DATE |
EXPIRATION
DATE |
REV. |
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ESH&Q Division |
08/17/2006 |
08/17/2006 |
08/17/2009 |
0 |
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