Issues Management Policy

Title:	Issues Management Policy
Publication date:	10/14/2021
Effective date:	10/1/2017

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

Gerasimos (Makis) Palamitzoglou
Risk & Issues Management Program Manager
Office of Institutional Assurance and Integrity
gpalamitzoglou@lbl.gov

Title:	Issues Management Policy
Publication date:	10/14/2021
Effective date:	10/1/2017

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	Manual
07.03.001.000	Occurrence Reporting (RPM)	Policy
PUB-3000, Ch. 15	Occurrence Reporting (ES&H Manual)	Policy
PUB-5519	Issues Management Program Manual	Manual
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
N/A	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
N/A	LBNL Radiation Protection Program	Program
N/A	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

Gerasimos (Makis) Palamitzoglou
Risk & Issues Management Program Manager
Office of Institutional Assurance and Integrity
gpalamitzoglou@lbl.gov

J. Revision History

Date	Revision	By whom	Revision Description	Section(s) affected	Change Type
10/14/2021	0.3	G.Palamitzoglou	Periodic review: no policy changes. Updated contact information and fixed broken Implementing Documents links	I, J	Editorial
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

Title:	Issues Management Policy
Document number	04.02.003.000
Revision number	0.3
Publication date:	10/14/2021
Effective date:	10/1/2017
Next review date:	10/14/2024
Policy Area:	Contractor Assurance
RPM Section (home)	Contractor Performance Management
RPM Section (cross-reference)	none
Functional Division	Office of Institutional Assurance and Integrity
Prior reference information (optional)	none

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