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**QUALITY MANAGEMENT OFFICE (QMO)**

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######### SELF-ASSESSMENT PLAN ![](media/image2.png){width="1.3333333333333333in" height="1.3229166666666667in"}

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######### FISCAL YEAR 2006

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######### Jan. 31, 2006

######### Revision 0

**PREPARED BY
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

> **J. Wilke, QMO**

**REVIEWED BY
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

> **S. Stein, QMO**

# APPROVED BY:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**R. Lebel, Manager, QMO**

File Code: QP00.2AR-.05-SHS

**Quality Management Office**

**Objectives, Functions, Measures of Performance, and Assessment
Activities**

**Fiscal Year 2006**

**1. 0 Introduction**

This document outlines the Self-assessment Plan (SAP) for the Quality
Management Office (QMO) for fiscal year 2006. The QMO uses
self-assessment as a means to continuously monitor and improve its work
processes and operations, ensure conformance to performance expectations
and support its vision and mission.

The functions performed by the QMO support institutional, ESH&Q
Directorate and internal initiatives. Therefore the QMO SAP includes
activities that support the Laboratory, the prime contract performance
measures (PEMP), the ESH&Q Directorate Self-Assessment Program and QMO
specific objectives. The QMO developed this SAP by following the
expectations outlined in the Integrated Assessment Subject Area.

The following sections describe the QMO Mission and Vision, its Key
Functions and Responsibilities as well as the specific activities to be
conducted. The QMO Manager will assign personnel to perform, report, and
track any required corrective/preventive actions resulting from
self-assessment activities. Where appropriate, assessment activities are
tracked in the BNL Institutional or Family Assessment Tracking System
(ATS).

**2.0 Vision and Mission Statements**

It is the **vision** of the Quality Management Office to have internal
and external customers recognize the organization as best-in-class
providers of quality services.

It is the **mission** of the Quality Management Office to be an
aggressive advocate for -- and support the line organization in --
developing programs, activities, and services that perpetuate the
integration of Quality, Environmental, and Integrated Safety Management
principles throughout Brookhaven National Laboratory. In accomplishing
this mission, the Quality Management Office will support execution of
all Laboratory mission objectives, critical outcomes, and contract
performance measures that are assigned to the Office.

**3.0 Key Functions and Responsibilities**

The domain of the Quality Management Office is defined by:

(1) key functions that are assigned to the QMO

(2) contract performance measures that are the responsibility of the QMO

(3) strategic imperatives of the Environment, Safety, Health & Quality
    (ESH&Q) Directorate that are supported by the QMO.

**3.1 Key Functions**

The Quality Management Office is responsible for the execution of three
major functions:

-   The **Quality Assurance Program**, which integrates quality
    methodologies throughout all BNL Management Systems to support
    effective planning, performance, control, assessment, and
    improvement of work processes; and the quality of products and
    services.

-   The **Standards Based Management System** **(SBMS)**, which is the
    mechanism by which the Laboratory develops, integrates, and
    demonstrates conformance to requirements: sets institutional
    standards; and conveys related information to staff.

-   The **Performance Based Management/Integrated Assessment Program
    Management System,** which supports the development, communication,
    and flow down of Laboratory Goals, Objectives, Measures and Targets
    as described in Appendix B of the DOE contract to organizations and
    to stewards of management systems.  This function establishes
    programs and processes to evaluate, assess, and report on
    organization and system performance with the objective of early
    identification and resolution of vulnerabilities that may impact
    achievement of Laboratory, Directorate, and/or QMO objectives.

In executing these functions, the Quality Management Office maintains
the following Laboratory-wide programs:

-   Assessment Tracking System (ATS);

-   Performance Reporting;

-   Lessons Learned;

-   Occurrence Reporting & Processing System (ORPS);

-   SBMS Website; and

-   Suspect/Counterfeit Items (S/CI).

**3.2 Key Responsibilities**

**3.2.1 Fiscal Year 2006 Contract Performance Measures**

The Quality Management Office is responsible for specific contract
Performance Measures and Targets within Performance Measure 5.2.1 and
Performance Objective 6.4.

The QMO is responsible for Performance Target 5.2.1.3 -- the
implementation of an effective issues management process. The QMO is not
directly responsible for Performance Target 5.2.1.4, but will support
this goal as necessary to insure BNL is successful in meeting this
target.

-   Performance Measure 5.2.1 - BNL will implement, maintain, and
    continually improve an integrated safety management system that:

    -   clearly states environmental and occupational health and safety
        (ESH) policies, programs and objectives appropriate for BNL
        operations,

    -   identifies ES&H risks and legal requirements,

    -   takes a proactive approach to ES&H risks and involves employees
        in the development and implementation of procedures,

    -   controls or eliminates ES&H risks to prevent accidents,

    -   monitors environmental management system (EMS) and occupational
        safety and health management (OSH) system performance, and

    -   ensures continual review, evaluation, and improvement of the
        system.

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-   Performance Target 5.2.1.3 - BNL will implement an effective issues
    management process that includes timely reporting, effective
    response, rigorous causal analysis, effective corrective action
    management, compliance with requirements, and useful lessons
    learned. "Issues" may be identified through assessments (internal or
    external), inspections or self-revealing events.

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-   Performance Target 5.2.1.4 - BNL will demonstrate management
    involvement through an effective management review process. BNL will
    institutionalize a formal management review process for all
    Directorates by the end of FY06. The management review will:

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-   Review ESH performance against the established annual goals and
    objectives,

-   Evaluate performance of departments and divisions in the Goal 5
    performance objectives, and Establish goals and objectives for the
    next year.

The QMO is responsible for leading the activities associated with
Performance Objective 6.4 -- Provide efficient, effective and responsive
management systems for Internal Audit and Oversight, Quality,
Information Management and Other Administrative Support Services as
Appropriate as follows:

-   Performance Measure 6.4.1 -- Demonstrate efficient and effective
    business management systems as validated by utilization and
    audit/assessment/benchmarking that drives continual improvement.

    -   Performance Target 6.4.1.1 -- Through the use of a third party
        or peer review team, BSA will evaluate the effectiveness,
        efficiency and responsiveness of their management systems.

**3.2.2 ESH&Q Directorate Strategic Imperatives**

In addition to the assigned functions and contract performance measures,
the Quality Management Office is committed to facilitating
implementation of the following ESH&Q Directorate Strategic Imperatives
as defined in the Directorate's FY 2006 Self-Assessment Plan:

-   Enable Laboratory to achieve OHSAS 18001 registration;

-   Support the Integrated Safety Management (ISM) Improvement Plan

-   Enable the Laboratory to develop credible self-assessments and
    sustainable corrective actions;

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-   Provide cost-effective, value-added services;

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-   Fully deploy tracking/trending process;

-   Create/Sustain a robust safety culture; and

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-   Maintain the public's confidence.

**4.0 Situation Analysis**

The focus of Fiscal Year 2006 is to continue to develop the initiatives
that were initiated in FY 2005, by enhancing their maturity, degree of
implementation, and impact on the Laboratory. Examples include
enhancement of the quarterly performance reporting for management and
the further development of the Corporate / Contractor Assurance Process,
the implementation of web-based tools to support the Requirements
Management function of SBMS, the design and deployment of an integrated
Event/Issues Management Process, and evaluation of BNL's current ATS and
the definition and implementation of improvements to this system.

In addition, a critical initiative at the Laboratory in FY 2006 is the
ISM Improvement Plan. This project has been initiated to respond to the
findings of fall 2005 ISM Readiness Review and, in doing so, prepare the
Laboratory for the DOE ISMS Evaluation scheduled for the second quarter
of FY 2007.

Collectively, these initiatives and the other functions and
responsibilities of the Quality Management Office require a high level
of performance and commitment in a period of significant budget
limitations. Accordingly, the QMO is actively monitoring the performance
of these initiatives and the capacity of its personnel to provide the
required sustained performance.

**5.0 Critical Objectives**

In order to achieve its mission and execute its key functions, contract
performance measures, and ESH&Q strategic imperatives, the Quality
Management Office has established a series of critical objectives that
it is using as a basis for developing performance measures. These
critical objectives are as follows:

1.  Provide subject matter expertise to the line organization to support
    the effective planning, performance, control, assessment, and
    improvement of work processes and management systems;

2.  Provide an enhanced and fully operational Standards Based Management
    System for use across the Laboratory;

3.  Provide leadership and support as required by the ISM Improvement
    Plan. The Quality Management Office has a lead role for several of
    the key elements of the ISM Performance Improvement Project:

-   Contractor Assurance Process

-   Event/Issues Management Process re-design

-   Improvement of the Assessment Tracking System

-   Improvement of the Integrated Assessment Program

-   Development and posting of lab wide procedures related to ISM on
    SBMS

4.  Provide tools and subject matter expertise to Laboratory personnel
    in the implementation of Performance Based Management / Integrated
    Assessment. Integrate key performance information to assist
    Laboratory senior management in decision-making and in
    implementation of the Assurance process.

5.  Support personal development, diversity and other initiatives at the
    Laboratory related to human resource management; and

6.  Effectively allocate and manage the financial resources assigned to
    the Quality Management Office for the achievement of its assigned
    key functions and responsibilities.

**6.0 Implementing Activities**

Each of the critical objectives -- as well as the key functions and
responsibilities -- identified above is executed by as series of
coordinated and detailed activities. These activities, organized by
critical objective, are listed below.

*[Critical Objective 1]{.underline} -- To provide subject matter
expertise as well as associated products and services to the line
organization to support the effective planning, performance, control,
assessment, and improvement of work processes and management systems.
(Many of the items below are products or analyses)*

-   The Quality Management Office will conduct meetings with Laboratory
    Quality Representatives on nominally a quarterly basis. These
    meetings will serve to disseminate information and receive feedback.
    Information on the meetings will be posted on the Quality Management
    Office website. The Office will explore the possibility of combining
    these meetings with other meetings (e.g., ESH Coordinators
    Meetings).

-   The Quality Management Office, in cooperation with Quality
    Representatives, will review the Quality Assurance Program
    Description (QAPD) and the Quality Management System Description
    (QMSD). Based on this review, the QAPD and QMSD will be updated, if
    appropriate. The results of the review will be formally communicated
    to BHSO.

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-   The Quality Management Office will coordinate an assessment of the
    Quality Assurance Program Description in coordination with the
    Environmental Management System and Occupational Health & Safety
    assessments.

-   The Quality Management Office will perform a quarterly roll-up of
    assessments against this plan and submit for incorporation into the
    ESH&Q Directorate Assessment Plan.

-   The Quality Management Office will provide a quarterly roll-up of
    assessments against the ESH&Q Directorate Assessment Plan.

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-   The Quality Management Office, in conjunction with the Procurement
    Office, will conduct a follow-up review of ESH&Q Risk Level A1/A2
    procurements when the revised "Supplier Evaluations" and
    "Inspections and Acceptance" Subject Areas have been posted on SBMS
    and a suitable period of time and number of A1/A2 procurements are
    placed.

-   The Quality Management Office will commission an independent
    assessment of the Quality Assurance Program Description.

*[Critical Objective 2]{.underline} -- Provide an enhanced and fully
operational Standards-Based Management System for use across the
Laboratory.*

-   The Quality Management Office will develop and implement a project
    plan for improving the Requirements Management process. This plan
    will include three major activities:

1.  Verification of Requirements

2.  Launch of Electronic Requirements Management Tools

3.  Contract Mapping

> Timely and effective execution of this project plan will require the
> significant support of and interaction with the Laboratory's
> Management System Stewards and Points-of-Contact.

-   The Quality Management Office will prioritize the remaining SBMS
    content development work to support the ISM Improvement Plan; and
    work with MS Stewards, POCs and SMEs to schedule this work within
    the ISM Improvement Plan framework.

*[Critical Objective 3]{.underline} -- Provide leadership and support as
required by the ISM Improvement Plan.*

-   See Section 5.0, Item 3 for a list of specific QMO activities that
    are essential to the effective execution of the *ISM Improvement
    Plan*.

-   The Quality Management Office will lead the effort to redesign and
    deploy the Event/Issues Management process. This revised process
    will include processes for event response, critique, causal
    analysis, corrective and preventive action planning development and
    action management and lessons learned.

-   In support of the ISM Improvement Plan, the QMO will provide
    periodic "tutorial workshops" on the various Quality-related subject
    areas as a means to refresh Quality Representatives and others
    regarding the requirements of the QAP. These tutorials may take
    place during Quality Representative Meetings.

-   The Quality Management Office will provide support for the OHSAS
    Phase III initiative.

*[Critical Objective 4]{.underline} -- Provide tools and subject matter
expertise to Laboratory personnel in the implementation of the
Performance Based Management / Integrated Assessmen. Integrate key
performance information to assist Laboratory senior management in
decision-making and in implementation of the Assurance process.*

-   The Quality Management Office will coordinate the development of a
    Quarterly Performance Report that will summarize performance (1) at
    the institutional level, (2) by BSA Risk Committee, (3) by
    management system, (4) by contract performance measure, and (5) a
    performance analysis of institutional data -- ORPS, non-ORPS events,
    PAAA issues and any recurring/programmatic issues. This report will
    identify high risk events of interest, performance measures, key
    initiatives, and emerging requirements, assessments of importance,
    and overall performance and areas of on-going risk. This is a
    critical element of the Assurance process and has high visibility
    with Laboratory senior management, the BSA Board, and DOE.

-   The Quality Management Office will work with Management System
    Points-of-Contact to develop the FY 2006 Required Assessments Table
    for Line Organizations (Integrated Assessment Subject Area).

-   The Quality Management Office will revise the Integrated Assessment
    Program Management System Description to include EMS and OSH
    management reviews, as well as reflect current IAP processes.

-   The Quality Management Office will develop and implement an
    improvement plan for the Assessment Tracking System (ATS), including
    benchmarking the PNNL and ORNL ATS, identification and
    prioritization of improvements to BNL's ATS, and working with BNL
    ATS users and BSD to complete the high priority/high impact items.
    This action also supports Critical Objective 3.

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-   The Laboratory S/CI Coordinator will conduct an annual trend
    analysis and report on S/CI activity and program performance.

-   The ORPS Coordinator will prepare four Quarterly Performance
    Analysis Reports.

-   Quality Management project engineers will participate in three Tier
    I inspections supporting line organizations.

*[Critical Objective 5]{.underline} -- To support personal growth
development and other initiatives at the Laboratory related to human
resource management*

-   The Quality Management Office will establish R2A2s for each person
    within the Office that are explicit, comprehensive, and aligned with
    the key functions and responsibilities of the Office. As
    appropriate, goals will be established for QMO staff in support of
    this self- assessment plan.

-   The Quality Management Office will employ the services of an outside
    consultant to conduct a 1/2 day, off-site, workshop on team building
    and to work with Office staff to improve their performance.

-   The Quality Management Office staff will establish personal goals
    for each staff member to promote diversity awareness by
    participating in at least one activity to promote, celebrate, or
    learn about diversity. Activities may include participation in an
    affinity group activity or celebration (e.g., African American
    Heritage Month, Hispanic American Heritage Month, Asian
    American/Pacific Islander Heritage Month, American Indian Heritage
    Month, Gay & Lesbian Pride Month, Disability Awareness Month, and
    Women History Month), providing assistance to the Laboratory
    Assistant Program, or participation in an EEO/AA, Sexual Harassment,
    or Diversity training course. The Quality Management Office will
    send one staff member to the 2006 Federally Employed Women's
    Conference or similar career development conference/seminar for
    women. The Quality Management Office will plan to present at the
    Annual National Business and Disability Conference in the fall of
    2006.

*[Critical Objective 6]{.underline} -- To effectively allocate and
manage the financial resources assigned to the Quality Management Office
for the achievement of it assigned key functions and responsibilities.*

-   The Quality Management Office Manager assigns budget responsibility
    for functional execution to the responsible staff person and holds
    them accountable for the financial (and functional) performance.

-   The Quality Management Office Manager has responsibility for
    management of the overall QMO budget.

**7.0 Attachments**

**7.1 Attachment A: Assessment Activities**

**7.2 Attachment B: FY 2006QMO Project Plan**

**7.3 Attachment C: FY06 Quality Management Office Performance Measures
and Targets, and Management Initiatives**

ATTACHMENT A -- ASSESSMENT ACTIVITIES

In order to evaluate the performance of the Quality Management Office in
achieving its critical objectives and in performing its key functions
and responsibilities, the following self-assessment activities are to be
conducted. Activities will be tracked in the Assessment Tracking System
as appropriate.

+----+-----------------------------------+--------------+-------------+
| *  | **Activity**                      | **Resp       | **Due       |
| *N |                                   | onsibility** | Date/**     |
| o. |                                   |              |             |
| ** |                                   |              | **          |
|    |                                   |              | Frequency** |
+----+-----------------------------------+--------------+-------------+
| 1  | Staff Meetings                    | R. Lebel     | At least    |
|    |                                   |              | monthly     |
+----+-----------------------------------+--------------+-------------+
| 2  | QMO Project Plan Status Meetings  | R. Lebel/J.  | Weekly      |
|    | -- these meetings will serve to   | Wilke        |             |
|    | assess progress of the QMO work   |              |             |
|    | scope for FY 06. (See Attachment  |              |             |
|    | B - QMO Project Plan)             |              |             |
+----+-----------------------------------+--------------+-------------+
| 4  | Staff R2A2 Review; Goals          | R. Lebel/    | 2/15/06     |
|    |                                   |              |             |
|    |                                   | J. Wilke     |             |
+----+-----------------------------------+--------------+-------------+
| 5  | Budget Review                     | R. Lebel     | At least    |
|    |                                   |              | quarterly   |
+----+-----------------------------------+--------------+-------------+
| 6  | Quality Representative Meetings   | R. Lebel /   |             |
|    |                                   |              |             |
|    |                                   | J. Wilke     |             |
+----+-----------------------------------+--------------+-------------+
| 7  | PEMP 5.2.1, and 6.4               | R. Lebel/    | 9/30/06     |
|    |                                   |              |             |
|    | See Attachment C.                 | J. Wilke/ J. |             |
|    |                                   | Usher        |             |
+----+-----------------------------------+--------------+-------------+
| 8  | Quarterly Data Calls and          | T. Baker/    | Quarterly   |
|    | Performance Reports for PEMP, MS, |              |             |
|    | Corporate Risk                    | J. Wilke     |             |
+----+-----------------------------------+--------------+-------------+
| 9  | Tutorials on Quality MS Subject   | J. Wilke     | Complete    |
|    | Areas                             |              | all by      |
|    |                                   |              | 12/06       |
+----+-----------------------------------+--------------+-------------+
| 10 | Interface with BHSO Counterparts  | All          | Ongoing     |
|    | and other DOE stakeholders as     |              |             |
|    | necessary                         |              |             |
+----+-----------------------------------+--------------+-------------+
| 11 | Interface with Sr. Management as  | All          | Ongoing     |
|    | necessary                         |              |             |
+----+-----------------------------------+--------------+-------------+
| 12 | Interface with Laboratory         | All          | Ongoing     |
|    | customers as necessary            |              |             |
+----+-----------------------------------+--------------+-------------+
| ** | **ESH&Q Self Assessment Plan**    |              |             |
| 13 |                                   |              |             |
| ** |                                   |              |             |
+----+-----------------------------------+--------------+-------------+
| 13 | Perform quarterly assessment      | J. Usher     | Quarterly   |
| .1 | against the ESH&Q SA Plan         |              |             |
+----+-----------------------------------+--------------+-------------+
| 13 | Format Quarterly Report to        | R. Lebel /   | 4/28/06     |
| .2 | standardize ESHQ input            |              |             |
|    |                                   | T. Baker     |             |
+----+-----------------------------------+--------------+-------------+
| 13 | Technical leadership, support for | S. Stein     | 9/30/06     |
| .3 | OHSAS III                         |              |             |
+----+-----------------------------------+--------------+-------------+
| 13 | Event/Issue Management Process -- | J. Usher     | QMO Project |
| .4 | develop and implement             |              | Plan        |
+----+-----------------------------------+--------------+-------------+
| 13 | Revise IAP                        | J. Usher     | QMO Project |
| .5 |                                   |              | Plan        |
+----+-----------------------------------+--------------+-------------+
| 13 | Coordinate Third Party Review --  | R. Lebel     | See Item 7  |
| .6 | PEMP 6.4                          |              |             |
+----+-----------------------------------+--------------+-------------+
| 13 | Support Lab's HR Program          | All          | Ongoing     |
| .7 |                                   |              |             |
+----+-----------------------------------+--------------+-------------+
| 13 | Maintain Property Inventory       | B. Evelly    | Ongoing     |
| .8 |                                   |              |             |
+----+-----------------------------------+--------------+-------------+

**ATTACHMENT B**

**FY2006 QMO PROJECT PLAN**

**ATTACHMENT C**

**FY06 QUALITY MANAGEMENT OFFICE**

**PERFORMANCE MEASURES AND TARGETS,**

**AND MANAGEMENT INITIATIVES**