Management Assessment

Berkeley Lab managers at all levels must regularly assess the performance of their organizations and functions to determine how well objectives and goals are being met.  Assessments by line managers focus on identifying and resolving both singular and systematic management issues and problems that may hinder the organization in achieving its scientific and operational objectives.  Managers should assess their processes for the following:

• Planning
• Organizational interfaces (internal and external to the organization)
• Integration of management systems (e.g., safety, security, quality, project)
• Use of performance metrics
• Training and qualifications
• Supervisory oversight and support

The management assessments should include an evaluation of such conditions as the state of employee knowledge, motivation, and morale; communication among workers; the existence of an atmosphere of creativity and improvement; and the adequacy of human and material resources.  The assessments should also involve direct observation of work so that the manager is aware of the interactions at a work location.  The observations can be supplemented with worker and customer interviews, safety and performance documentation reviews, and drills or exercises.

The results of management assessments must be documented and used as input to the organization's improvement process.  The documentation can include minutes of staff and operations meetings, progress reports, job expectation evaluations, inspection reports, and self-assessment reports.

Independent Assessment

Continuous Improvement

Continuous improvement is a combination of quality improvement and corrective actions that (1) uses feedback information to improve processes, products, and services; (2) prevents or minimizes quality or safety problems; and (3) when discovered, correct the problems that occur.  A quality or safety problem is a collective term that involves a deficiency in an activity, product, service, item characteristic, or process parameter; in an environment, safety, and health requirement; or in a legal and contractual requirement.  Managers at all levels have the responsibility to correct deficiencies and improve whenever possible on the processes, products, and services under their supervision.

Quality Improvement

Improvement in quality is a disciplined management process based on the premise that all work can be planned, performed, measured, and improved.  Line managers should ensure that the focus is on improving the quality of processes, products, and services by establishing priorities, promulgating policy, promoting cultural aspects, allocating resources, communicating lessons learned, and resolving significant management issues and problems that hinder the organization from achieving its objectives.  Management must balance safety and mission priorities when considering improvement actions.

A quality improvement process includes:

• Reviewing information and data on processes, products, or services to identify conditions adverse to quality and safety
• Analyzing the adverse conditions and determining the causes
• Segregating the processes, products, or services if the adverse conditions may lead to significant consequences, as determined by line management
• Developing alternative approaches for addressing the adverse conditions and preventing recurrence (e.g., reducing process variability or cycle time)
• Implementing the approved solutions
• Evaluating the improvements or corrections
• Providing lessons learned to other organizations

The quality improvement process should be part of the normal operation of all Berkeley Lab working groups and should be documented in the normal operational records and reports (e.g., minutes from staff and operations meetings; progress and activity reports; readiness reviews; assessment and inspection reports).  Conditions that have significant adverse consequences require separate disposition reports that document the actions taken to correct the problems.

Corrective Action

Findings, concerns, and deficiencies identified from assessments or quality improvement processes should be addressed immediately. If corrective action cannot be done on the spot and if the consequences to mission, program, operations, and ES&H are significant, the corrective actions must be tracked by the responsible manager through the Berkeley Lab Corrective Action Tracking System (LCATS). LCATS is managed by the Office of Assessment and Assurance (OAA). OAA provides regular status reports on the corrective actions to advise Laboratory management on progress and completion.

When there is a need for additional planning and scheduling, some assessments and quality improvement processes may require formal corrective action plans. The corrective action plans allow senior Lab management to review risk management, funding, and resource allocation issues. Once approved by the appropriate Laboratory authority, the corrective actions also must be tracked through LCATS.

The Office of Assessment and Assurance also performs trending and root cause analysis to prevent recurrence of the finding, concern, or deficiency.

Standards and Requirements

Section 3 of the OAP conforms to the following quality assurance criteria described in 10 CFR 830.120, Quality Assurance Requirements, and DOE O 414.1, Quality Assurance:

• Criterion 3, Quality Improvement
• Criterion 9, Management Assessment
• Criterion 10, Independent Assessment

Section 3 also complies with requirements described in paragraph 4 of DOE O 5480.19, Chg. 1, Conduct of Operations Requirements for DOE Facilities, and DOE P 450.4, Safety Management System Policy .