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Issues Management Policy

    Title:

    Issues Management Policy

    Publication date:

    6/29/2016

    Effective date:

    1/2/2012

    BRIEF

    Policy Summary

    Berkeley Lab administers an Issues Management Program and processes for issue- identification, tracking, resolution, and verification and validation of corrective action effectiveness. The Laboratory also identifies, analyzes, and corrects adverse trends, and promotes continuous feedback and performance improvement.

    Who Should Read This Policy

    All Berkeley Lab employees

    To Read the Full Policy, Go To:

    The POLICY tab on this wiki page

    Contact Information

    Theresa Triplett
    Issues Management Program Manager
    Office of Contractor Assurance
    TATriplett@lbl.gov

    Title:

    Issues Management Policy

    Publication date:

    6/29/2016

    Effective date:

    1/2/2012

    POLICY

    A. Purpose

    This policy is designed to implement and maintain an Issues Management system that promptly identifies issues and develops effective corrective actions to ensure successful resolution and prevention of recurring issues.

    B. Persons Affected

    This policy applies to all Lawrence Berkeley National Laboratory (Berkeley Lab) employees.

    C. Exceptions

    Employee-sensitive issues and investigations such as, but not limited to, allegations of harassment, intimidation, retaliation and discrimination, and employee/employer relationship issues (such as performance improvement actions and grievances) are not managed through the Issues Management Program.

    Immediately corrected issues; service requests, such as Information Technology (IT) Help Desk tickets; and Facilities general, preventive, and corrective maintenance work requests are not entered in the CATS Database. Similarly, ethical/integrity, health services, employee concerns, traffic incidents, security breaches, and ergonomics evaluation issues are not entered in the CATS Database.

    D. Policy Statement

    Berkeley Lab must implement and maintain a system to promptly identify issues and effective corrective actions to prevent reoccurrence of the same or similar issues in accordance with requirements set forth in U.S. Department of Energy (DOE) Contract No. DE-ACO2-05CH11231 and Laboratory policy. Issues management is performed using a risk-based approach to ensure that the appropriate levels of analysis, corrective action development, documentation, and effectiveness evaluation are commensurate with federal and Berkeley Lab requirements and with the management of risks that:

    • Affect Berkeley Lab's ability to meet contract and regulatory requirements
    • Adversely impact the reliability of the Berkeley Lab mission and operations
    • Adversely impact the environment, public, and employee safety and health

    For specific details, refer to the Issues Management Program Manual (PUB-5519).

    E. Roles and Responsibilities

    Role

    Responsibility

    Laboratory Management

    Communicates and reinforces the importance of proactively identifying, reporting, and managing issues.

    Division Management

    Assures that personnel are working to the requirements outlined in this policy and the Issues Management Program manual

    Office of Institutional Assurance

    Provides oversight and administration for the Issues Management Program, which includes maintaining and revising program manuals, maintaining the Corrective Action Tracking System (CATS) and Lessons Learned and Best Practices databases, and providing technical guidance to Berkeley Lab staff with regard to the Issues Management Program

    Employees

    Adhere to the requirements outlined in this policy and the Issues Management Program manual

    F. Definitions/Acronyms

    Term

    Definition

    Apparent Cause

    The dominant reasonable cause(s) of an issue that management has the control to fix through effective corrective actions. There may be more than one apparent cause for a given incident.

    Corrective Action

    An action that addresses the apparent or root cause of an issue, prevents recurrence or significantly reduces the likelihood of recurrence, and demonstrates endurance.

    Graded Approach

    A method by which the levels of analysis, mitigation, documentation, verification. and validation are determined commensurate with risk severity.

    Issue

    A broad term that refers to any safety or operational incident, condition, or circumstance that:

    • Results or could result in injury, damage, loss, or noncompliance (actual or near-miss incident)
    • Represents a program, safety, or operational deficiency (audit or assessment finding, or performance deficiency as identified through trending and analysis or metrics)
    • Adversely affects the achievement of mission, strategic and business objectives (risks)

    Issues Management

    The process by which issues are managed, tracked, and evaluated through resolution to prevent recurrence

    Lessons Learned

    A good work practice or innovative approach that is captured and shared to promote repeat application or an adverse work practice or experience that is captured and shared to prevent recurrence.

    Policy

    Statements or directives from the federal, state, or local government; the University of California; or Berkeley Lab senior management that set a course of action, define acceptable conduct, or implement governing principles. Example: LBNL Site Access

    Procedure

    A series of specific steps to be followed to accomplish work or to carry out a policy or requirement. Procedures are controls meant to mitigate risk, improve efficiency, or assure compliance. Examples: Obtaining a Berkeley Lab badge, maintaining the Laboratory's 12 kV electrical system, completing a travel expense form

    Program

    A course of action, typically comprising multiple coordinated projects, established to accomplish an organization's strategic objectives or to improve its performance. A program's duration may be perpetual or undetermined, and success is measured in terms of benefits derived. A program has a generally defined scope or mission, with specific objectives, and a prescribed governing structure with defined roles and responsibilities.

    Requirement

    A specific obligation to perform an action mandated by Berkeley Lab senior management or the federal, state, or local government; or to comply with the Laboratory's contract with DOE; or to comply with agreements made between the Laboratory and its corporate manager, the University of California

    Risk Level

    The severity / significance rating assigned to an issue to ensure that appropriate levels of analysis oversight and resolution are commensurate with Berkeley Lab requirements. Risk levels are stated as high, medium, or low.

    Root Cause

    The underlying or basic cause of an issue that can reasonably be identified and management has the control to fix, and when fixed, will preclude recurrence or significantly reduce the likelihood of recurrence of the same or similar issue. The root cause is typically one level further in analysis beyond an apparent cause.

    G. Recordkeeping Requirements

    Records that are generated as a result of implementing policy requirements must be maintained in accordance with the records-retention requirements outlined in the Requirements and Policies Manual (RPM) and Berkeley Lab implementing documents.

    H. Implementing Documents

    Document number

    Title

    Type

    PUB-3032

    Personal Property Manual

    System

    07.03.001.000

    Occurrence Reporting

    Policy

    PUB-3000, Ch. 15

    Occurrence Reporting

    Policy

    PUB-5519

    Issues Management Program Manual

    System

    PUB-201

    Requirements and Policies Manual (RPM)

    Policy

    11.07.003.000

    Audit Resolution and Follow-Up Policy

    Policy

    04.02.004.000

    PAAA Policy

    Policy

    (tbd)

    Laboratory Procurement Standard Practices Manual, Section 46.1, Subcontract Quality Assurance

    Process

    04.02.004.001

    Price-Anderson Amendments Act (PAAA) Compliance Program Manual

    Manual

    RPP

    LBNL Radiation Protection Program

    Program

    (tbd)

    Policy on Corrective Actions and Plans of Action and Milestones (POAMs) (IT internal)

    Policy

    OIA-OCA-0001

    Corrective Action Tracking System (CATS) Database User Manual

    Manual

    OIA-OCA-0002

    Lessons Learned and Best Practices Database User Manual

    Manual

    I. Contact Information

    Theresa Triplett
    Issues Management Program Manager
    Office of Contractor Assurance
    TATriplett@lbl.gov

    J. Revision History

    Date

    Revision

    By whom

    Revision Description

    Section(s) affected

    Change Type

    6/29/2016

    0.2

    T. Triplett

    Periodic review

    All

    Minor

    2/15/2013

    0.1

    L. Young

    Update SRD and Implementing Documents info

    Document Info

    Editorial

    1/2/2012

    0

    T. Triplett

    Initial

    all

    Major

    DOCUMENT INFORMATION

    Title:

    Issues Management Policy

    Document number

    04.02.003.000

    Revision number

    0.2

    Publication date:

    6/29/2016

    Effective date:

    1/2/2012

    Next review date:

    6/29/2019

    Policy Area:

    Contractor Assurance

    RPM Section (home)

    Contractor Performance Management

    RPM Section (cross-reference)

    none

    Functional Division

    Office of Contractor Assurance

    Prior reference information (optional)

    none

    Source Requirements Documents

    • Contract 31, Section H.30, Contractor Assurance
    • PUB-3111, Quality Assurance Program Description
    • PUB-5520, UC Contractor Assurance System Description
    • DOE Order 232.2, Occurrence Reporting and Processing of Operations Information
    • DOE Order 210.1A, DOE Corporate Operating Experience Program, Attachment 1, Contractor Requirements Document
    • DOE Order 225.1B, Accident Investigations, Attachment 1, Contractor Requirements Document

    Other Driving Requirements

    Implementing Documents

    Document number

    Title

    Type

    PUB-3032

    Personal Property Manual

    System

    07.03.001.000

    Occurrence Reporting

    Policy

    PUB-3000, Ch. 15

    Occurrence Reporting

    Program

    PUB-5519

    Issues Management Program Manual

    System

    PUB-201

    Requirements and Policies Manual (RPM)

    Policy

    11.07.003.000

    Audit Resolution and Follow-Up Policy

    Policy

    04.02.004.000

    PAAA Policy

    Policy

    (tbd)

    Laboratory Procurement Standard Practices Manual, Section 46.1, Subcontract Quality Assurance

    Process

    04.02.004.001

    Price-Anderson Amendments Act (PAAA) Compliance Program Manual

    Manual

    RPP

    LBNL Radiation Protection Program

    Program

    (tbd)

    Policy on Corrective Actions and Plans of Action and Milestones (POAMs) (IT internal)

    Policy

    OIA-OCA-0001

    Corrective Action Tracking System (CATS) Database User Manual

    Manual

    OIA-OCA-0002

    Lessons Learned and Best Practices Database User Manual

    Manual

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