EFCOG Best Practice #2

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Title:  Self-Assessment Program

Facility: Lawrence Berkley National Laboratory

Best Management Practices:

The LBNL Self-Assessment Program is a four-tiered assessment program that uses the ISM functions and principles as its core assessment criteria. Each of the four types of assessments is conducted by different reviewers and has different focuses, but the assessments are all aligned with the ISM functions and principles. As a result, feedback on ISM effectiveness can be accomplished at various organizational levels and also be "rolled-up" at the institutional level. The four types of self-assessments are:

Why the best practice is used:

The LBNL Self-Assessment Program is an on-going process to (1) validate that ISM is implemented at all organizational levels; (2) evaluate and manage ES&H performance; and (3) identify opportunities to improve ISM effectiveness.

What the benefits of the best practice are

Self-evaluations of various ES&H issues can be accomplished because of the different focuses of the four self-assessments. However, because the self-assessments are aligned with ISM functions and principles, the four-tiered self-assessment program provides a cohesive system to evaluate ISM performance at all organizational levels. Providing a seamless system to describe ISM performance has been exceedingly beneficial in addressing ISM contractual requirements and requirements from DOE ISM orders and directives.

WHAT PROBLEMS/ISSUES ARE ASSOCIATED WITH THE BEST PRACTICE

A key issue is to ensure that the four types of self-assessments are sufficiently different so that there is no redundancy or duplication of effort. Having different assessment objectives and different types of reviewers has helped to alleviate any redundancy. Another issue is to develop unique performance indicators for each of the assessments. In particular, performance indicators for the division self-assessment program are developed and updated annually and requires consensus approval by the divisions.

HOW SUCCESS OF THE BEST PRACTICE IS MEASURED

The performance indicators and criteria for each type of self-assessment provide the quantitative and qualitative information to measure ISM implementation and effectiveness. The information is "rolled-up" annually into an institutional ES&H self-assessment report. The annual report is a key document used by the Lab’s corporate office (UCOP) and DOE to rate the Lab’s ES&H and ISM performance. The report is also the basis for continuous improvement with institutional issues and division deficiencies identified. Success is measured by the fact that (1) the LBNL self-assessment results are consistent with the ES&H performance ratings given by UCOP and DOE; (2) the self-assessment results are the basis for the annual ISM validation conducted by DOE; and (3) the issues and deficiencies identified in the self-assessments are generally accepted by LBNL divisions, and corrective actions are thus undertaken resulting in year-to-year improvements in the Lab’s ES&H/ISM programs.

DESCRIPTION OF PROCESS EXPERIENCE USING THE BEST PRACTICE

Much time and effort is needed to develop and obtain consensus of the assessment ES&H performance indicators. Ownership of the performance indicators is a key element for the success of the program. Once the indicators are in place, the four types of assessments are conducted throughout the year. At the end of the year, a roll-up and validation of the assessment data and information is performed by an independent organization (i.e., LBNL Office of Assessment and Assurance). The roll-up report summarizes the noteworthy practices, institutional and divisional opportunities for improvement, and a numerical score for ES&H performance by division and by ISM core functions. Follow-up actions are then identified to address the opportunities for improvement.