NASA Procedural Requirements

NPR 1800.1B Effective Date: January 30, 2007 Expiration Date: January 30, 2012

Subject: NASA Occupational Health Program Procedures

Responsible Office: Office of the Chief Health & Medical Officer

Chapter 7. Occupational Health Review Process

7.1 Introduction

This chapter establishes a method for performing and documenting the results of Agency Occupational Health reviews and delineates requirements for biennial evaluations of major NASA HQ and field locations that occur on NASA property. For purposes of the audit element of the review process, the OCHMO defines a requirement as a mandatory element for a program or function. Requirements shall include NASA Policy Directives (NPDs), NASA Procedures and Requirements (NPRs) and other external regulations and consensus standards applicable to NASA.

The review process shall be comprehensive enough to provide Center Senior Management with a status of the effectiveness of their Center's programs. By definition this must include the provision of sufficient resources commensurate with the Center's size, population, and mission to achieve and maintain desired effectiveness.

7.2 Purpose

Regular reviews of medical and occupational health services are required to assure protection of the health of the NASA workforce. Biennial OCHMO reviews shall be designed to help the Agency identify and mitigate risk, provide a consistent, high level of health care to participants across the Agency and identify best practices and innovative solutions that provide greater operational effectiveness and efficiency.

Occupational health (OH) reviews include a compliance audit component. They also provide an opportunity for open dialogue with Center personnel and are used as a forum to advocate for appropriate support for health- related services. The Review Team provides technical help, guidance on best practices, support on Agency occupational health initiatives, and facilitates specialized training for emerging health threats or new requirements as needed to enhance the competency of health discipline employees.

The OH components assessed shall include medical care provided at each Center's Occupational Medicine Clinic (including emergency care capability and coordination with other departments, medical quality assurance, and health clinic environment of care); preventive health activities; the employee assistance program; federal workers' compensation; fitness facilities; industrial hygiene; health physics; sanitation and food safety programs; and medical aspects of other programs such as emergency preparedness and childcare facilities.

During the alternate years, when a review is not conducted at a Center, the Center shall perform a self evaluation using criteria provided in the most recent occupational health review conducted at the Center, or some other approved equivalent methodology. A record of areas reviewed, names of individual(s) conducting evaluations, dates and locations shall be retained on file at the host center. Each Center shall provide a self- evaluation to the OCHMO in the same month of the alternate year in which they are normally audited. The Center report shall delineate areas of substantial improvement and/or degradation of their occupational health program.

7.3 Process Description

Occupational health reviews shall compare Center policies, procedures, and practices to regulatory and other compliance requirements, agency policy requirements and consensus standards. A written report shall be produced from the review findings and provided to the Center for response. The appropriate Mission Associate Administrator, Institutional Corporate Management, and Safety and Mission Assurance Directorates shall be appropriately copied for their reference of findings associated with health, environmental compliance and/or safety, respectively. Nonconformance findings shall be tracked to closure as further detailed below.

Occupational health reviews shall begin with scheduling review dates with the Centers' occupational health Contracting Officer Technical Representative(s) (COTR) or their appointed representative. The COTR or their representative shall act as the Centers' primary point of contact for the review process. The schedule for the program surveys is as follows:

A letter shall be sent to the Center Director or Facility Manager, at least 60 days ahead of the review dates, announcing the upcoming review and requesting the associated support. This shall be followed with an e-mail to the COTR containing the review questionnaires and a request for specific Center documentation. The COTR shall distribute the requests to the Centers' occupational health representatives. The Centers' occupational health representatives shall answer the questions. The primary point of contact shall return the questionnaires to the OCHMO Review Team Leader via e-mail. The requested Center-specific documentation shall be returned to the OCHMO Review Team Leader, who will distribute it to the Review Team for their assessment prior to the Center review.

The review shall begin with an in-briefing of the principals involved in the review process. The Center shall provide multi-disciplinary coverage for the entire review period. The in-briefing shall provide a forum for an exchange of information and details regarding the review. It shall also provide the Centers with current OHMS information that may affect them and provide feedback on previous review process improvements. The in-briefing shall be an opportunity for the OHMS Review Team to offer expert information and advocacy while on site. The Centers shall present their top occupational health concerns and a status of any open or unresolved nonconformance findings from previous occupational health reviews at the in-briefing.

After the in-briefing, each reviewer shall meet with their subject matter counterpart to clarify questionnaire answers, discuss Center occupational health programs and processes and plan area visits. Information shall be collected and verified through interviews, tours of work areas, observation of activities and the surrounding work environment and conditions, documentation of reviews, and record inspections.

The out-briefing shall be presented to the Center Director or the Deputy as a verbal executive summary. It shall focus on the strengths and weaknesses found during the review. A written report shall be prepared within 45 days of out-briefing.

The written report shall be a reiteration of the same issues expressed in the verbal executive summary, plus a detailed report of all review findings. Centers shall have 45 days after receipt of the written report to reply to the OHMS Review Team Leader with a corrective action plan that addresses remedial actions for the non-conformance findings associated with the review process.

Nonconformance findings shall be closed within 6 months or as negotiated. The Center shall keep the OHMS Review Team Leader informed of the status of corrective action activities particularly if a delay is anticipated. Corrective actions shall only be "closed" when the anomalous condition associated with the non-conformance no longer exists.

A re-visit to a Center to review the occupational health program, or portion thereof, shall be performed when important program elements are non-conforming or incomplete or if, in the opinion of the discipline reviewer and team leader, the program or a portion thereof, is sufficiently weak or degraded as to require a review before the next biennial review. Follow-up review elements shall concentrate only on the deficient areas.

Working documents, reports, and results shall be retained on file or in the Agency Health Electronic Database (AHED) for use and future examination.

Findings shall be categorized as follows:

Commendation: Best practices that far exceed requirements or are ingenious time or cost-saving solutions to problems.

Recognition: Acknowledgement of significant improvements or progress toward Center occupational health program goals.

Observation: A noteworthy comment such as a notation of a significant difference compared with other Centers' practices. Such comments are neither positive nor negative in nature.

Opportunity for Improvement: A condition that meets compliance requirements, but could be improved. Opportunities for Improvement will be accompanied by "Recommendations" in the written report but are not required to be addressed in the Center's corrective action plan.

Nonconformance: A divergence from a compliance requirement (Federal, State, local, NASA Agency, NASA Center, etc.) or consensus standard (ANSI, HACCP, NIOSH, NFPA, etc.). These findings require Center response in the corrective action plan.

7.4 Responsibilities

7.4.1 The Chief Health and Medical Officer shall be responsible for:

a. Ensuring that planned program evaluations of NASA facilities are conducted to determine the value and adequacy of Center occupational health programs and that program resources are appropriately provided

b. Reviewing Flight Medicine aspects of NASA's occupational health processes

c. Determining the need for more frequent specialized surveys on aspects of, or the entire, occupational health program.

7.4.2 The Director of Occupational Health shall be responsible for the following:

a. Assuring overall occupational health review process efficacy

b. Appointing the team lead for Center reviews

c. Reviewing and releasing occupational health review reports

d. Approving or disapproving lessons learned suggestions prior to their implementation

7.4.3 The OHMS Review Team Leader shall be the Agency's primary representative for the review and shall be responsible for the following:

a. The overall effective implementation of the Agency's occupational health review

b. Initiating contact with each Center prior to review

c. Providing Review Team members with discipline-specific point of contact information for each Center, including names, e-mail addresses, and phone numbers

d. Coordinating and exchanging information with each Center primary point of contact

e. Establishing each Center's review schedule and associated meetings

f. Representing the OHMS at each Center's review in-briefing meeting

g. Overseeing all aspects of the review on site

h. Coordinating real-time issues and problems, as they arise, during the review process

i. Consulting with the Agency's Director of Occupational Health, as needed during the review, regarding nonconformance findings

j. Representing the OHMS at each Center's out briefing meetings

k. Coordinating and preparing review reports

l. Conducting "lessons-learned" meetings with Review Team Members as soon as feasible after each occupational health review

m. Compiling strength and weakness summaries for inclusion into each Center's written report summary

n. Ensuring that the written report is consistent with the verbal out briefing, and is released within 45 days.

o. Tracking Centers' nonconformance findings to closure

p. Continually improving the occupational health review process based on lessons-learned

7.4.4 Center Directors shall be responsible for the following:

a. Appointing a Center point of contact, with sufficient authority for reviews, to coordinate Center on-site reviews with the OHMS, and to provide ready access to facilities, and other logistical support

b. Supporting the review effort with adequate resources and personnel

c. Attending the out-briefing or designating the Deputy Center Director to attend if he/she is unavailable

d. Assuring the corrective action plan addresses all nonconformance findings

e. Providing the corrective action plan to the Agency

f. Providing adequate resources to resolve corrective actions

g. Ensuring implementation of the requests for action designated in the review

h. Assuring notification of the OHMS for Center reviews, audits and visits from outside regulatory bodies, such as the Occupational Safety and Health Administration (OSHA), the Nuclear Regulatory Commission (NRC), etc.

7.4.5 Individual Agency Review Team members shall be responsible for the following:

a. Being the subject matter points of contact for their Center counterparts

b. Reviewing returned Center questionnaires, and previous audit/assessment information prior to the review

c. Coordinating and exchanging information with each Centers' subject matter points of contact

d. Establishing individual review times and coordinating meetings with Center counterparts

e. Performing their discipline-specific review of the Centers' occupational health program

f. Reporting real-time issues and problems to the Review Team Leader, as they arise, during the review process

g. Representing the OHMS at the review out-briefing or coordinating with other Review Team members who will attend the out-briefing meetings, as applicable

h. Coordinating, preparing and entering data into the AHED

i. Providing the team lead with a summary of strengths and weaknesses of the Center pertinent to their disciplines for the summary report

j. Attending "lessons-learned" meetings as they are scheduled

k. Reviewing draft occupational health review reports

l. Reviewing, and either accepting or rejecting, nonconformance closure rationale

m. Updating the status of nonconformance findings in the AHED

n. Coordinating nonconformance findings with the team leader in support of chain-of-command reporting

7.4.6 The Center primary point of contact shall be responsible for the following:

a. Coordinating and exchanging information with each review Team Member counterpart

b. Providing a discipline-specific point of contact list to the Review Team Leader, including names, mail and e-mail addresses, and phone numbers

c. Distributing review questionnaires from the Review Team Leader to Center personnel

d. E-mailing completed questionnaires to the Agency Review Team Leader on time

e. Providing other requested documentation via e-mail, fax, etc. to the Agency Review Team Leader

f. Arranging for badging and escort of the Review Team

g. Coordinating requirements for bringing review equipment onto the Center, including any forms that must be completed and submitted for equipment use at the Center (e.g., laptop PCs, cameras, PDAs, etc.)

h. Arranging for a private work area and logistic support for the Agency Review Team

i. Arranging in-briefings and out-briefings and associated meeting rooms

j. Supporting the review schedule and associated meetings

k. Providing access to Center internal locations subject to the scope of the review

l. Providing on-site access to additional Center documentation as needed

m. Overseeing the review for the Center

n. Coordinating real-time issues and problems, as they arise, during the review process

o. Coordinating nonconformance findings as needed with Center Management

p. Representing the Center at the review out-briefing meetings

q. Overseeing preparation of the corrective action plan

r. Tracking Centers' nonconformance findings to closure

7.4.7 Center Discipline-specific points of contact shall be responsible for the following:

a. Being the subject matter points of contact for their Agency Review Team counterparts

b. Emailing completed questionnaires to the Center primary point of contact on time

c. Coordinating and exchanging occupational health discipline information with the appropriate Review Team counterpart

d. Being available to support their Agency Review Team counterpart with the review process

e. Supporting the review in-briefing meetings

f. Coordinating individual review times and meetings with Agency Review Team counterparts

g. Providing objective evidence of implementation of requirements (e.g., documentation, records, licenses, etc.).

h. Escorting Agency Review Team personnel

i. Reporting real-time issues and problems to the Center primary point of contact, as they arise, during the review process

j. Coordinating with the Agency Review Team on specific discipline findings prior to the out briefing

k. Representing the Center at the review out-briefing meetings as applicable

7.4. 8 The OHMS Administrative Assistant to the Director shall be responsible for:

a. Maintaining an overall schedule of each review to assure that critical milestones are met, such as review announcement letters, pre-review meetings, review letters, six-month status reports, lessons learned meetings and responses to corrective action plans

b. Assuring review announcement letters are initiated in sufficient time to allow for OHMS and Center actions on questionnaires and document requests

c. Scheduling in-house pre-review meetings

d. Preparing the final report from AHED data

e. Preparing the executive summary and detailed report for distribution to the Center within 45 days of completing the review

f. Scheduling lessons learned meetings after reviews

g. Providing a lessons learned report

7.5 References

a. 29 CFR Part 1960 "Basic Program Elements for Federal Employee Occupational Safety and Health Programs and Related Matters."

b. 29 U.S.C. 668, Section 19 of the Occupational Safety and Health Act of 1970, as amended.

c. NPD 1210, NASA Surveys, Audits, and Reviews Policy

d. NPD 1800.2B, NASA Occupational Health Program

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