Brookhaven Science Associates

Brookhaven National Laboratory

Independent Oversight Report

SA 03-02

Review of Self-Assessment Program

of the

Human Resources and Occupational Medicine Division

September 16, 2003

Prepared by:

John Usher, Reviewer Date

> Independent Oversight Office

Approved by:

Robert McNair, Manager Date

Independent Oversight Office

Contents

1.0 Introduction [1](#introduction)

1.1 Purpose and Scope [1](#purpose-and-scope)

1.2 Review Process [1](#review-process)

1.3 Review Criteria [2](#review-criteria)

2.0 Program Summary [3](#program-summary)

2.1 Criterion 1: Approach to Self-Assessment
[3](#criterion-1-approach-to-self-assessment)

2.2 Criterion 2: Deployment of Self-Assessment
[6](#criterion-2-deployment-of-self-assessment)

2.3 Criterion 3: Results from Self-Assessment
[9](#criterion-3-results-from-self-assessment)

3.0 Conclusions [11](#conclusions)

3.1 Strengths [11](#strengths)

3.2 Areas for Improvement [12](#areas-for-improvement)

3.3 IAP Management System Programmatic Issues
[13](#iap-management-system-programmatic-issues)

Exhibits

Exhibit 1 - Documents Reviewed [14](#__RefHeading___Toc38940660)

Exhibit 2 -- Personnel Interviewed [15](#__RefHeading___Toc38940662)

Exhibit 3 - Documents Referenced [16](#__RefHeading___Toc38940663)

## Introduction

### Purpose and Scope

This report presents the results of Independent Oversight's review of
the Self-Assessment (SA) Program of the Human Resources and Occupational
Medicine (HR&OM) Division. As an element of the Integrated Assessment
Program (IAP), the Independent Oversight (IO) Office is chartered to
independently verify the effectiveness of Brookhaven National
Laboratory's Self-Assessment Program. To accomplish this, the IO Office
performs a review of Directorates or other organizations reporting to
the Laboratory Director in accordance with the requirements and
guidelines provided in the IAP Management System Description. Reviews
are identified and scheduled in the FY 2003 Program Plan: Review of
Organizational Self-Assessment Programs \[FY03 IO Review Plan\].

FY03 reviews focus on the organization's "approach" to self-assessment,
the status of "deployment" and the "use of results" to improve
performance. Specifically, IO will review how the organization is
planning to implement the self-assessment program, how the organization
conducts the self-assessment program, and how the results from
self-assessment are analyzed and used to improve performance. In the
course of this review, comparison of the current status of the HR&OM SA
Program to that reported in **Independent Oversight Report SA 00-03,
Evaluation of the Human Resources Division** **Self-Assessment Program
\[IO Report SA 00-03\]** was performed to measure progress since the FY
2000 evaluation. The IO Reviewer and the HR&OM Division Director agreed
that this review would cover only the Human Resources (HR)
responsibilities for the HR&OM Division since the Occupational Medicine
Clinic had (1) merged with HR in January 2003, (2) been reviewed as part
of the ESH&Q Directorate in FY02 as reported in **Independent Oversight
Report SA 02-02, Review of Self-Assessment Programs of the Environment,
Safety, Health and Quality Directorate**, and (3) been reaccredited by
the Accreditation Association for Ambulatory Health Care (AAAHC) in
March 2003.

### Review Process

This review formally began on May 8, 2003, with an inbriefing conducted
with personnel from HR. This meeting served to introduce the IO
Reviewer, John Usher, who provided information on review objectives,
methodology, review criteria, and schedule. The inbriefing also served
to inform the IO Reviewer about HR and to identify key personnel
involved in the planning and implementation of self-assessment.

The following data and collection methods were used during the review:

-   Document Reviews (Exhibit 1)

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-   Interviews (Exhibit 2)

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-   Documents Referenced (Exhibit 3)

Interviews were conducted using prepared questions tailored to address
the review criteria (see Section 1.3) in terms of key business
factors/performance objectives. Notes were prepared during each
interview to record the information gathered. Comments, concerns, and
follow‑up actions were also documented after each interview.

An outbriefing was conducted on September 3, 2003, with personnel from
HR. At this meeting, the IO Reviewer summarized results of the review
and submitted a draft report for review by HR. The meeting also gave HR
personnel the opportunity to provide feedback to the IO Reviewer on the
review process.

### Review Criteria 

The IO assessment process evaluates an organization's self-assessment
program against the criteria published in the **FY03 IO Review Plan**.
These criteria are:

1.  Approach

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1.  The scopes of planned assessment activities are comprehensive, have
    a strong technical basis, and are balanced with work activities.

2.  The methods for conducting key scheduled assessments are defined and
    are commensurate with types of assessments planned and performance
    information desired.

3.  Management and staff involvement commensurate with their
    responsibilities is evident.

4.  Key supporting organizational processes (tracking/trending systems,
    causal analysis, critiques, etc.) and tools are developed.

5.  Organizational plans/procedures address regulatory and/or SBMS
    drivers for assessment activities.

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2.  Deployment

 

1.  Assessments are completed as scheduled. Planned assessment
    activities have been revised as appropriate based on new or changing
    information.

2.  Assessments are documented and communicated as planned.

3.  Assessment results are evaluated/analyzed to a degree commensurate
    with the type of assessment. Strengths are identified.
    Corrective/improvement actions are identified, prioritized, assigned
    to specific owners, and assigned due dates. All conditions are
    tracked to closure.

4.  Evidence of timely self-identification of issues exists. Significant
    issues are brought to the attention of management and disclosed to
    regulatory/oversight agencies in accordance with contractual
    obligations.

5.  Management involvement is evident.

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3.  Results

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1.  Sustained excellence and/or improved operational performance are
    evident for key areas of Laboratory operations, such as mission
    achievement and retention/expansion of core competencies.

2.  Evidence exists that there is an appropriate connection between
    results of organizational self-evaluation and development of
    strategic/institutional plans.

Further detailed information supplementing the review criteria is
provided in the **FY03 IO Review Plan**
(<http://www.io.bnl.gov/safy03.doc>).

## Program Summary

This review covers the HR&OM Division excepting the Occupational
Medicine Clinic as discussed previously. HR organizational/functional
areas addressed in this review included Employee Relations, Staff
Development, Compensation, Salary Administration, Labor Relations,
Benefits, Employment and Immigration, and Employee and Guest Records.
The HR&OM Division Director is also the Steward of the SBMS Management
System: Human Resources.

A discussion and analysis of data collected for the review of the HR&OM
Division is presented for each criterion. Areas that demonstrated
positive performance or programmatic strengths (criteria exceeded) are
identified with a (+). Areas where criteria are met but not exceeded are
unmarked. Areas that indicated opportunities for improvement (criteria
not met or partially met) are noted using a (-).

### Criterion 1: Approach to Self-Assessment

The HR Quality Assurance (QA) Representative prepared the HR
Self-Assessment Plan. The HR&OM Division Director approved the Plan. The
Plan (Rev. 0) is dated March 31, 2003.

The scope of the SA program is largely comprehensive in addressing the
Division's products and services, ES&H, human capital, and the Human
Resources Management System. Financial management is not explicitly
addressed in the SA Plan though effective financial management is
evident. Managers select appropriate methodologies for assessment
activities from a list of methods defined in the SA Plan. It is evident
that activities are appropriately prioritized per categories defined in
the SA Plan. Managers, staff, and key stakeholders are appropriately
involved in planning assessment activities. Processes for supporting the
organizational SA programs are in place, although Division personnel do
not use the Family Assessment Tracking System available to them.
Evidence exists that organizational managers appropriately consider
SBMS, contractual, and regulatory drivers in developing performance
goals/objectives and in planning and scheduling assessment activities,
although not all BNL required assessments relevant to HR were
acknowledged in the SA Plan.

1.  **The scopes of planned assessment activities are comprehensive,
    have a strong technical basis, and are balanced with work
    activities.**

Assessment activities are prioritized, as defined in the SA Plan, based
on legal compliance, critical outcomes, contractual requirements/DOE
Orders, management system/subject area compliance, customer service, and
effective operations. **(-)** HR intends that a specific priority be
identified for each assessment activity in Attachment 2 to the SA Plan,
but not all Assessment Items have documented Priority Categories. The
scope of the SA Plan emphasizes "high risk and cost areas affecting
\[HR\] and the \[Human Resources\] management system." HR managers
appropriately consider results of previous assessments in planning
assessment activities.

**(+)** The SA Plan is based on a framework that ensures a comprehensive
perspective of organizational performance. Planned assessments "address
at least one of the Laboratory's Assessment Planning and Evaluation
Criteria": Leadership Commitment and Involvement; Human Resource
Development and Management; Customer Focus and Satisfaction; Process
Management; Business and Operational Results; and Compliance with Laws,
Regulations and Contractual Requirements. Specific linkage for each
assessment activity is included in Attachment 2. The SA Plan is also
based on the Human Resources Management System.

The SA Plan addresses "services and systems provided by functional
groups within the \[HR\] Division; Lab-wide Human Resources trends which
indicate the effectiveness of the management system and human resources
programs; and environmental, safety and health performance in \[HR\]
Division facilities and operations." The SA Plan specifically
incorporates Administration, Benefits, Child Development Center,
Compensation, Employment, Employee Relations, Employee and Guest
Information Systems, Labor Relations, ES&H, Staff Development, and
Training. **(-)** It is noted that documented Assessment Items for Labor
Relations addressed disciplinary practices and grievance process but did
not address contract negotiations with bargaining unit. The Division
Director described improvements in negotiating practices including use
of "win-win" tactical approach. **(-)** It is also noted that Financial
Management is not explicitly included in the SA Plan, although HR
managers interact with the HR Business Operations Manager in reviewing
budget and performance versus spending plans.

As mentioned previously, the SA Plan addresses "services and systems
provided by functional groups within \[HR\]." **(+)** Customer Focus and
Satisfaction is a key element of the SA Plan. Day to day operations and
assessment activities include numerous examples of customer focus
involving frequent, direct interaction with customers: Benefits, Child
Development Center, Compensation, Employee and Guest Information
Systems, Employee Relations, Employment, Labor Relations, and Staff
Development. Expectations of BNL senior management are communicated
through regular interactions (including presentation of statistical
information) with the BNL Policy Council. Input from bargaining unit
personnel is obtained prior to meetings and feedback is solicited
following meetings. DOE customer expectations are reflected in legal and
contractual obligations.

The effectiveness of previously completed corrective actions is
appropriately considered during planning. The FY 2002 Self-Evaluation
Report, Section V. Human Resources Improvement Planning lists
improvements planned for both the HR Division and the Human Resources
management system.

Results from external assessments are incorporated into the
organization's self-assessment and annual self-evaluation process. The
FY 2002 Self-Evaluation Report evidences incorporation of results from
reviews by Internal Audit, a Supporting Assessment Measure (SAM)
conducted jointly with DOE-BAO, benchmarking comparisons, review by the
BNL Employee Benefits Committee, and licensing and accreditation
activities for the Child Development Center. HR also responded
appropriately to the IO FY00 evaluation of the HR self-assessment
program.

External lessons learned are incorporated into the organization's
self-assessment process. **(+)** HR incorporates external lessons
through benchmarking activities, attendance at conferences and
workshops, and participation in peer groups including reviews of other
DOE organizations' HR programs.

2.  **The methods for conducting key scheduled assessments are defined
    and are commensurate with types of assessments planned and
    performance information desired.**

Assessment activities are assigned to qualified personnel including
appropriate use of subject matter experts. HR managers and other
personnel well versed in the areas being assessed conduct
self-assessment activities. Appropriately qualified personnel conduct
Environmental Assessments and Tier I Inspections.

The HR&OM Director's expectations for self-assessment are documented in
the SA Plan, Section 4. Responsibilities. Specific responsibilities
include developing assessment approaches, conducting and documenting
assessments, and developing and implementing corrective actions.
Additionally, roles and responsibilities for self-assessment are
communicated to HR personnel through R2A2s and performance goals and
objectives. These expectations are reinforced at management and staff
meetings.

HR managers ensure that independent assessments and peer reviews are
considered and incorporated into the self-assessment process, as
appropriate. For example, the Child Development Center undergoes
licensing and accreditation reviews and is monitored by a parents'
group. HR incorporates results from BNL Internal Audit Office reviews
(e.g., salaries paid) into the SA process. The SA Plan contains
acknowledgement of this FY03 IO Office review of the SA Program. HR also
accommodates independent and peer review through focus groups formed to
evaluate various HR services and/or products. In FY02 "a review team of
stakeholders" conducted a Maturity Evaluations of the R2A2 Process. HR
also obtains a peer perspective through various benchmarking activities.

HR defines and uses an appropriate mix of information sources (SA Plan
Section 9. under Assessment Method Definitions) including quantitative
characterization, compliance checks, systematic examinations of
systems/functions, audits, surveys, and focus groups. Assessment Methods
are listed under each "Assessment Item" in Attachment 2 to the SA Plan.
**(-)** It is noted that two Assessment Items (IS-01 and IS-02) each
covered two different aspects of performance: timeliness and
effectiveness. The responsible manager acknowledged that these aspects
of performance actually are measured separately, and that existing items
would each be split into two new items.

Assessment activities do not typically impact the work of other
organizations or other personnel. Many assessment activities are
integrated into the normal performance of the work being measured, such
as the accumulation of statistical information or focus groups reviewing
specific systems/functions. Assessment activities such as Tier I
Inspections or Environmental Assessments are planned to involve the
personnel in the work areas being assessed in the assessment process.

3.  **Management and staff involvement commensurate with their
    responsibilities is evident.**

Planning involves managers and staff members as appropriate to ensure
that all aspects of the organization's operations are evaluated. The HR
QA Representative solicited input from, and provided assistance to,
managers during the development of the SA Plan especially focused on
Attachment 2, Assessment Items. The SA Plan states, "The HR Quality
Representative formulates an overall description of the HR assessment
plan and meets with HR managers to formulate assessment items for their
area of responsibility." HR managers solicit feedback regarding
performance objectives from staff through staff meetings, the
performance appraisal and individual goal planning process, and frequent
informal contacts.

**(-)** It is noted that "update of the organization\'s self-assessment
program for the current year" was not completed by December 31 per the
SBMS Subject Area: Integrated Assessment. The HR&OM Division Director
approved the HR SA Plan (Rev. 0) on March 31, 2003.

4.  **Key supporting organizational processes (tracking/trending
    systems, causal analysis, critiques, etc.) and tools are
    developed.**

HR has an effective process for analyzing and trending the results of
assessment activities. **(+)** HR uses "Assessment Report Templates"
available and saved on a shared computer disk drive (intranet) to
facilitate the communication, and analysis, of results of assessment
activities for each individual "Assessment Item" listed in Attachment 2
to the SA Plan. HR managers are required to prepare semi-annual and
year-end reports using the reporting templates per instructions
contained in Attachment 1 to the SA Plan. The HR QA Representative
prepares a year-end summary report for the Division using the
accumulated results from the completed templates. In addition to the HR
intranet, databases (including PeopleSoft modules) are used to
accumulate, report, and analyze information related to assessment
activities. **(+)** Trending is also evident in the quarterly HR&OM
Statistical Summary reports provided to the BNL Policy Council. **(+)**
Analysis of results is also evident in the "HR&OM Innovations" listing
prepared by the Staff Development Manager.

HR uses the templates discussed previously as the primary tracking
process for most assessment activities. HR managers are required to
"develop and implement corrective actions" per the instructions in
Attachment 1 to the SA Plan. The SA Plan also requires that HR managers
"discuss and obtain approval from the Director, \[HR&OM\], for actions
that have significant impact or cost." Managers regularly discuss status
of actions at HR management meetings. The HR&OM Division does not use
the Family Assessment Tracking System.

Records demonstrating effective planning, timely completion of
assessments, and analysis of results are exemplified by the completed
templates maintained on the shared disk drive. Some assessment
activities result in specific detailed reports, such as the Compensation
System Self-Assessment and the R2A2 Process Maturity Evaluation. Other
records include the quarterly Statistical Summary, HR&OM Innovations,
and the year-end Self Evaluation Report.

5.  **Organizational plans/procedures address regulatory and/or SBMS
    drivers for assessment activities.**

HR assessment activities are specifically linked to organizational
and/or management system objectives and measures as evidenced in
Attachment 2 to the SA Plan. Priority Categories include Legal
Compliance, Critical Outcome, and Contractual Requirement/DOE Order as a
means of identifying which assessment items are linked to these
particular requirements.

Tier I and Environmental Assessments are identified in the SA Plan.
**(-)** Some required assessments (e.g., Contract Administration and
Procurement Quality) per the Required Self-Assessments attachment to the
Integrated Assessment subject area are not identified in the SA Plan.
The IO reviewer notes that the HR QA Representative indicated intent to
add these required assessments to the SA Plan and accurately stated that
assessment aids for these required assessments were not available at the
time the HR SA Plan was issued. The IO reviewer also understands that
the HR QA Representative was under the impression that the required
assessments would not be formally required until the required assessment
aids were issued; however, BNL management intended that required
assessments be addressed in SA Plans upon issuance of the revised
Integrated Assessment Subject Area in January 2003. The HR SA Plan,
Section 5 acknowledges the requirement for completing assessment aids
("forms") provided for SBMS management systems in order to conduct
assessments "properly."

### Criterion 2: Deployment of Self-Assessment

Assessment activities are conducted as scheduled. Schedules are adjusted
based on changing priorities as determined by organizational managers.
Results of assessment activities are documented and communicated to
responsible HR managers for review and analysis. Key assessment results
are regularly discussed and analyzed at management meetings. Managers
evaluate assessment results to identify both strengths and opportunities
for improvement. Necessary improvement actions are identified and
communicated to responsible managers and stakeholders.

1.  **Assessments are completed as scheduled. Planned assessment
    activities have been revised as appropriate based on new or changing
    information.**

Almost all assessment activities are ongoing, as opposed to discrete,
assessments. The vast majority of activities are scheduled for
completion at the end of the fiscal year (September 30). Assessment
status is updated mid-year (March 31) using the templates provided on
the HR intranet. Assessment status is discussed regularly at management
meetings. Those activities scheduled for completion in the first two
quarters of FY03 have been completed as evidenced by, for example,
incorporation of results in the Statistical Summary.

The HR SA Plan acknowledges the potential for "Mid-year Changes to SA
Program." The SA Plan states, "\[HR\] Managers remain sensitive to
occurrences that may indicate the need to amend the \[SA\] Plan." At the
time of this IO review, Rev. 0 of the SA Plan was in effect. Individual
assessment items are also adjusted when warranted.

**(+)** Customer input/feedback is solicited throughout the fiscal year
using approaches such as focus groups, working groups, surveys,
one-on-one contacts, and periodic management and staff meetings.
Customer feedback approaches are built into many of the services
provided by the HR Division associated with, for example, Employment,
Benefits, Compensation, Employee Relations, Employee and Guest
Information Systems, Training, and Labor Relations.

2.  **Assessments are documented and communicated as planned.**

Completed Self-Assessment Report templates constitute ample evidence
that results are provided to responsible managers. Additionally,
specific assessment reports documented, for example, the Compensation
System Self-Assessment and the R2A2 Process Maturity Evaluation. Results
of other assessment activities are reported as documented in the
Statistical Summary, which is provided to both the Division Director and
the BNL Policy Council.

The assessment schedule is managed to ensure information is available to
support timely management decisions. Since many of the assessment
activities are ongoing, results are available to HR&OM and BNL
management on a real-time basis through PeopleSoft modules, for example.
Statistical information is updated quarterly to support the presentation
to the BNL Policy Council. Updates to Self-Assessment Report templates
are scheduled to support mid-year and year-end Division reviews. As
previously noted, information regarding assessment activities is
regularly discussed at HR management meetings.

3.  **Assessment results (internal and external) are evaluated/analyzed
    to a degree commensurate with the type of assessment. Strengths are
    identified. Corrective/improvement actions are identified,
    prioritized, assigned to specific owners, and assigned due dates.
    All conditions are tracked to closure.**

**(+)** HR managers interviewed unanimously evidenced a philosophy of
continuous improvement. Improvements are documented in FY02 Human
Resources Innovations attached to FY 2002 Self-Evaluation Report. The
attachment lists, for example, multiple improvements ("Innovations") in
Benefits, Compensation, Employment, Employee and Guest Information
Systems, HR Management, and Staff Development. The list of innovations
is updated on a regular basis. It is noted that the draft list for FY03
has added OMC innovations.

The HR&OM Director and Level 2 managers clearly consider risk to BNL and
cost benefit in prioritization; numerous examples are highlighted in
HR&OM Innovations. The Director articulated prioritization for both
HR&OM and BNL, for example, in focusing on career development for HR
personnel and diversity considerations in recruiting for BNL. It is
noted that availability of resources is a key consideration in
prioritization. Causal factors are addressed as part of improvement
planning.

HR&OM management validates key improvements as documented in the
year-end evaluation. Independent, external assessments (e.g., those
conducted by DOE) also serve to validate improvements. Self-assessment
items are planned to measure the effectiveness and efficiency of
improvements that have been implemented.

4.  **Evidence of timely self-identification of issues exists.
    Significant issues are brought to the attention of management and
    disclosed to regulatory/oversight agencies in accordance with
    contractual obligations.**

The identification of potential noncompliances with nuclear safety rules
(Price-Anderson Amendments Act \[PAAA\]) is largely not applicable to
personnel within the HR&OM Division; although some aspects of Employee
Concerns could impact BNL's compliance with 10 CFR 708, Criteria and
Procedures for DOE Contractor Employee Protection Program. The Human
Resources Management System references DOE O 442.1A, Department of
Energy Employee Concerns Program, which in turn references PAAA and 10
CFR 708. In the past, concerns have been brought to the attention of the
BNL PAAA Coordinator through HR and BNL management.

Results are analyzed to determine potential impacts on SBMS documents.
As discussed previously, HR's Self-Assessment Program specifically
addresses the Human Resources Management System and the Subject Areas
maintained per the management system. In FY02, for example, HR reviewed
and updated the Performance Appraisal Subject Area. As noted previously,
the R2A2 process was also evaluated in FY02. Assessment items also
address the Guests and Visitors Subject Area.

Results are appropriately considered for publication in the BNL Lessons
Learned Program. HR personnel authored a BNL Lessons Learned addressing
employee concerns during an investigation. HR personnel communicate
lessons learned with the BNL community through focus groups, committees
and one-on-one contacts. HR personnel also communicate lessons learned
externally to BNL through involvement in DOE and other peer groups.

5.  **Management involvement is evident.**

HR managers, in consultation with the HR QA Representative, authored the
planned SA Items listed in Attachment 2 to the SA Plan. Managers
directly participate in work conducted or supported by the Division, and
self-assessment is built into many of the activities before, during, and
after the activities themselves. As examples, HR managers interview BNL
and prospective BNL personnel; HR managers lead focus groups and/or
committees formed to implement and evaluate HR processes or BNL
processes for which HR is responsible; managers lead and/or participate
in scheduled assessment activities addressing compliance with DOE or
other requirements. The small size of HR organizations necessitates
managers' involvement in both day-to-day activities and assessment of
these activities. HR managers interact regularly with personnel from
other BNL organizations to solicit input and feedback.

**(+)** HR managers participate in the review of information that is
entered into databases managed by the Division as a measure of the
quality of information in these systems. Managers also observe training
courses and other presentations. Some HR managers mentor other managers
as well as non-managerial personnel as a way of both observing and
improving performance.

**(+)** HR managers are individually responsible for Assessment Items as
indicated in Attachment 2 to the SA Plan. Completed templates provide
ample evidence that HR managers participate in the analysis and
evaluation of assessment results. Additional evidence of analysis is
documented in the HR&OM Statistical Summary and in the FY 2002
Self-Evaluation Report.

As noted previously, HR managers are individually responsible for
Assessment Items as indicated in Attachment 2 to the SA Plan including
the development, and implementation, of actions designed to improve
performance. If warranted, action plans are reviewed and approved by the
Division Director. Status of actions is discussed at biweekly HR
meetings and documented semiannually in self-assessment templates.
**(+)** Notably, HR Innovations also provides documentation (and
verification) of improvements in HR performance.

### Criterion 3: Results from Self-Assessment

HR provided input to BNL's Year End Self-Evaluation Report for previous
years, though not for FY 2002, summarizing performance results for
Critical Outcomes and Performance Measures that were the responsibility
of HR. Critical Outcome performance reporting was accomplished via
computerized submittals to the BNL Integrated Information Management
System (IIMS). HR prepared a document entitled, "Human Resources
Division FY 2002 Self-Evaluation Report" evaluating performance for FY
2002, highlighting improvements, and describing Improvement Planning for
both the HR Division and the Human Resources Management System for FY
2003.

Assessments and resulting actions are appropriately prioritized and
tracked to closure. Managers review the need for changes in action due
dates and approve rescheduling. Assessment reports reviewed provide
evidence of timely self-identification of issues/concerns. Results are
reviewed at management and staff meetings, and action status is
discussed. Several examples of improved operational performance were
noted throughout the Division as documented in HR Innovations. It is
clear that organizational managers are aware of vulnerabilities and
areas for improvement. There is appropriate linkage between the SA Plan
and BNL's Institutional Plan.

1.  **Sustained excellence and/or improved operational performance are
    evident for key areas of Laboratory operations, such as mission
    achievement and retention/expansion of core competencies.**

Progress towards achievement of near-term and long-term goals and
objectives is evident and affirmed twice annually as documented by HR
managers in completed SA Templates. Many near-term objectives feed
long-term goals as with implementation of individual PeopleSoft modules
leading to the integrated PeopleSoft system. Progress is also documented
quarterly in the HR&OM Statistical Summary. **(+)** HR amply evidences
maintenance of excellence in established activities and implementation
of Innovations. Specific examples of improvements resulting from the
self-assessment process listed in the FY02 document and the draft FY03
document can be seen to originate from SA Items. Examples include new
benefit programs, expansion of the use of non-base pay programs,
distribution of visa status records to BNL Departments, increased
synergy between Employment and the BNL Diversity Office, assuming
ownership of the guest registration process, and achieving instructor
certifications to enable in-house delivery of training programs.

**(+)** Performance has been enhanced and made more efficient as
evidenced by Innovations implemented and consistency in performance even
with considerable reduction in number of personnel. The HR Division
staffing level has been reduced from approximately 33 to 29 FTEs in
recent years. The organization has maintained a high level of
performance and has sought and accepted additional areas of
responsibility, such as managing the BNL Guest Information System.

**(+)** Evidence exists that customers and other stakeholders value the
products and services of the organization. HR managers regularly receive
feedback, both solicited and unsolicited, from customers and
stakeholders. Managers are responsive to this feedback. Evidence that
customers and stakeholders value the products and services of HR is best
exemplified by the ongoing contacts with the BNL community seeking
support and/or expertise in areas including employment, employee
relations, employee benefits, and training.

2.  **Evidence exists that there is an appropriate connection between
    results of organizational self-evaluation and development of
    strategic/institutional plans.**

Improvement actions are either acted upon at the
organization/Directorate level or communicated to BNL senior management
to be included in the Laboratory's improvement agenda, as appropriate.
Many of HR's assessment activities address Laboratory-level performance
by design, and, as such, results from these activities directly impact
Laboratory-level performance. Other activities address HR's performance
solely or the Human Resources Management System. Communication of
results is evident particularly because of the quarterly presentations
of HR statistics to the Policy Council. HR input (direct or indirect as
through the Policy Council) to Laboratory-level (strategic) plans
clearly reflects analytical evaluation of assessment results.

In addition to responsiveness demonstrated through the annual
self-evaluation process, HR demonstrated responsiveness to other
independent or external assessments as exemplified via improvements
addressing the Areas for Improvement and the Recommendations made in
**IO Report SA 00-03**:

-   **The Human Resources Division has not updated its SA Plan for
    FY00.** HR updated its SA Plan for FY00 and developed updated SA
    Plans for FY01, FY02, and FY03. It is noted that the SA Plan for
    FY03 was not issued by December 31, 2002, per the Integrated
    Assessment Subject Area.

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-   **The SA Plan does not provide a description of the overall SA
    Program.** The FY03 HR SA Plan, Section 3. Process contains a
    description of "developing and implementing the SA Plan."

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-   **The SA Plan does not assign stewardship or support
    responsibilities for the SA Program.** The FY03 HR SA Plan,
    Section 4. Responsibilities details responsibilities for the
    Division Director, the HR QA Representative, and the HR managers.
    The Section clearly defines responsibilities for stewardship,
    support, and implementation of the HR SA Program.

## Conclusions

### Strengths 

The HR Division evidences improvement in the organizational
Self-Assessment Program since FY00 over what was already recognized as
an effective program. The SA Program is more formally documented and
more comprehensive in scope. Approaches to self-assessment activities
include much more than just traditional audits and represent a
performance-based concept. Roles and responsibilities for
self-assessment are clearly defined. Processes for documenting results
of activities, analyzing results, identifying opportunities for
improvement, and tracking actions are in place. The SA Plan documents an
annual cycle of continuous improvement in effectiveness and efficiency,
represents a forward-looking approach, and provides linkage with the BNL
Institutional Plan in planning and achievement of longer-term goals and
objectives.

-   HR managers interviewed uniformly articulated commitment to
    improving organizational and individual performance as reflected in
    the services/products provided by HR organizations. As mentioned
    previously, specific improvements are documented in Innovations.
    Notably, managers indicated a desire for further improvement even in
    areas that were highly rated by customers/stakeholders. One manager
    exemplified a philosophy of continuous improvement by stating, "It's
    not perfect yet."

-   **Efficiency in operations** is also a key tenet of HR's management
    philosophy and practice. Performance has been enhanced and made more
    efficient as evidenced by Innovations implemented and consistency in
    performance even with considerable reduction in number of personnel.
    The organization has maintained a high level of performance and has
    sought and accepted additional areas of responsibility, such as
    managing the BNL Guest Information System and through the merger
    with the Occupational Medicine Clinic.

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-   The HR SA Program **encompasses both Division operations and the
    Human Resources Management System.** Planned assessment items
    address at least one of BNL's Assessment Planning and Evaluation
    Criteria. The SA Plan specifically incorporates Administration,
    Benefits, Child Development Center, Compensation, Employment,
    Employee Relations, Employee and Guest Information Systems, Labor
    Relations, ES&H, Staff Development, and Training.

-   HR has **processes in place for analyzing and trending** the results
    of assessment activities as well as organizational and Laboratory
    performance. HR uses **Assessment Report Templates** to facilitate
    the communication, and analysis, of results of assessment
    activities. Trending is evident in the quarterly **HR&OM Statistical
    Summary** reports provided to the BNL Policy Council. Analysis of
    results is also evident in the **HR&OM Innovations** listing
    attached to the annual Self-Evaluation Report.

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-   Customer Focus and Satisfaction is a key element of the HR SA
    Program. Day to day operations and assessment activities include
    numerous examples of customer focus involving frequent, direct
    interaction with customers: Benefits, Child Development Center,
    Compensation, Employee and Guest Information Systems, Employee
    Relations, Employment, Labor Relations, and Staff Development.
    Customer input/feedback is solicited throughout the fiscal year
    using approaches such as focus groups, working groups, surveys,
    one-on-one contacts, and periodic management and staff meetings.
    Ample evidence exists that customers and other stakeholders value
    the products and services of the organization. Expectations of BNL
    senior management are communicated through regular interactions with
    the BNL Policy Council. DOE customer expectations are reflected in
    legal and contractual obligations.

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-   HR incorporates **lessons learned through benchmarking** activities,
    attendance at conferences and workshops, and participation in peer
    groups including reviews of other DOE organizations' HR programs.
    The Division Director participates in joint meetings with DOE and
    contractor personnel and solely with other contractor HR Directors
    to facilitate the frank sharing of information regarding HR
    management and practices. Additionally, much of the statistical
    analysis conducted by the HR Division involves comparisons with
    national, regional, local, and other similar-to-BNL organizations.

### Areas for Improvement 

-   HR did not have an updated, approved FY03 SA Plan in place by
    December 31.

> **Recommendation:** The HR&OM Director should ensure that FY04 SA Plan
> is prepared and approved by December 31, 2003, per the SBMS Subject
> Area: Integrated Assessment.

-   The SA Plan does not include all "Required Self-assessments" per the
    Exhibit attached to the SBMS Subject Area: Integrated Assessment
    (Issued: January 2003).

> **Recommendation:** The HR QA Representative indicated that these
> required assessments would be incorporated into the HR SA Plan as the
> appropriate BNL Management System Stewards issued the assessment aids.
> The QA Representative should proceed as indicated.

-   Financial Management is not explicitly included in the HR SA Plan.

> **Recommendation:** Since HR managers interact regularly with the HR
> Business Operations Manager in reviewing budget and performance versus
> spending plans, the HR QA Representative should ensure that this
> ongoing practice is incorporated in the SA Plan without the need for
> additional documentation to be generated.

-   Assessment Items for Labor Relations do not address contract
    negotiations with the bargaining unit.

> **Recommendation:** The Division Director should ensure that an
> assessment item to address contract negotiations with the union be
> added to the SA Plan for those fiscal years when appropriate.

-   Assessment Items IS-01 and IS-02 each cover two different aspects of
    performance: timeliness and effectiveness.

> **Recommendation:** The responsible manager stated that these would
> each be split into two new items. The responsible manager should
> proceed as indicated.

-   A Priority Category is not identified for each assessment item in
    Attachment 2 to the SA Plan.

> **Recommendation:** The QA Representative should review each
> assessment item with the responsible manager and ensure that the
> appropriate priority is assigned and listed in Attachment 2.

### IAP Management System Programmatic Issues

It is acknowledged that some of the issues discussed below are known to
BNL management and the IAP Management System Steward and Point of
Contact, and that efforts may be underway to address these issues. These
issues are noted here for emphasis.

An HR manager expressed concern about the timing (January 2003) of the
most recent revision to the Integrated Assessment Subject Area
incorporating new required assessments and the need for organizations to
update their SA Plans shortly after initial issuance/approval. The
manager also expressed concern about the appearance of being out of
conformance to the Integrated Assessment Subject Area while awaiting the
issuance of Assessment Aids to enable the determination of whether or
not specific required assessments applied to HR.

While not directly relevant to IAP, an HR manager expressed concerns
about the "bureaucracy" that SBMS has become and the effect on BNL
resources of the need for numerous hand-offs of documents for review.
The manager perceived a need for determination of an accurate, complete
process flow for SBMS document development with an objective of
improving/streamlining the process. These concerns were communicated to
the IO Office Manager for incorporation into the list of potential
topics for Institutional Independent Assessment for FY04.

[]{#__RefHeading___Toc38940660 .anchor}Exhibit 1 - Documents Reviewed

1.  FY 2003 Human Resources Self Assessment Plan, Rev. 0: March 31, 2003

2.  Human Resources Division FY 2002 Self-Evaluation Report, February
    12, 2003

3.  Human Resources -- Occupational Medicine Innovations -- FY 2003
    \[Draft\]

4.  Human Resources and Occupational Medicine Division Statistical
    Summary, 3/31/2003

5.  Human Resources FY 2003 Self-Assessment Report \[Template\]

6.  Human Resources Division FY 2002 Self-Assessment Quarterly Report
    \[Template\]

7.  Brookhaven National Laboratory, Self Assessment - BNL Compensation
    System, July 2002

[]{#__RefHeading___Toc38940662 .anchor}Exhibit 2 -- Personnel
Interviewed

1.  W. Hempfling, HR&OM Director

2.  R. Kelly, Manager, Compensation, and QA Representative

3.  M. Pandorf, Manager, Staff Development

4.  B. Miller, Supervisor, Employee and Guest Records

5.  M. Kipperman, Manager, Employment

6.  S. Foster, Manager, Employee Relations

7.  B. Hulse, Division Administrator, and Scientific Personnel
    Representative

8.  D. DiMeglio, Manager, Benefits

9.  D. Dowling, Manager, Labor Relations

[]{#__RefHeading___Toc38940663 .anchor}Exhibit 3 - Documents Referenced

1.  SBMS Management System Description: Integrated Assessment Program,
    Issue Date: July 1999

2.  BNL Independent Oversight Office FY 2003 Program Plan: Review of
    Organizational Self-Assessment Programs (December 12, 2002)

3.  U.S. Department of Energy Contract with Brookhaven Science
    Associates, DE-AC02-98CH10886

4.  Appendix B (to DE-AC02-98CH10886), Critical Outcomes, Objectives,
    and Performance Measures FY 2003 Brookhaven National Laboratory
    (04/18/03)

5.  Year End Self-Evaluation - Brookhaven National Laboratory - Fiscal
    Year 2002

6.  Brookhaven National Laboratory Draft Institutional Plan FY 2003 --
    FY 2007, May 2002

7.  SBMS Subject Area: Integrated Assessment, Effective Date: January
    2003

8.  SBMS Subject Area: Internal Controlled Documents, Effective Date:
    May 2002

9.  SBMS Subject Area: Performance Goals and Measures for Employees,
    Effective Date: October 2001

10. SBMS Subject Area: Performance Appraisals, Effective Date: September
    2002

11. SBMS ESH Standard 1.2.1, Corrective Action Management and Tracking
    for External and Internal Assessments, Rev. 5, Effective Date:
    December 2002

12. Brookhaven National Laboratory Independent Oversight Report SA
    00-03, Evaluation of the Human Resources Division Self-Assessment
    Program (March 24, 2000)

13. Brookhaven National Laboratory Independent Oversight Report SA
    02-02, Review of Self-Assessment Programs of the Environment,
    Safety, Health and Quality Directorate (September 11, 2002)