FSME Procedure Approval

Conducting Self-Assessments of the Integrated 

Materials Performance Evaluation Program (IMPEP) 

SA-123

Issue Date: June 24, 2011

Review Date: June 24, 2014

Terrence Reis 

Acting Director, MSSA /RA/ Date: 6/24/2011

A. Duncan White 

Branch Chief, MSSA /RA/ Date: 6/8/2011

Leira Cuadrado 

Procedure Contact, MSSA /RA/ Date: 6/8/2011

ML111580392 

NOTE 

Any changes to the procedure will be the responsibility of the FSME Procedure Contact. 

Copies of the FSME procedures are available through the NRC website. 
Procedure Title: 

Conducting Self-Assessments of 

the Integrated Materials 

Performance Evaluation Program 

(IMPEP) 

Procedure Number: SA-123

Page: 1 of 7 

Issue Date: 

6/24/2011

I. INTRODUCTION

 This document describes the procedure for conducting self-assessments of the 

Integrated Materials Performance Evaluation Program (IMPEP). This procedure 

explains the responsibilities of each of the parties involved in conducting an IMPEP 

self-assessment, the suggested frequency, schedule, scope and documentation of the 

self-assessments, and response or actions to recommendations made by the IMPEP 

self-assessment working group. 

II. OBJECTIVES

A. To provide the guidelines to be followed by the working group to conduct IMPEP 

self-assessments. 

B. To establish the time interval on which IMPEP self-assessments should be 

conducted.

C. To provide guidelines to review, capture, and document lessons learned and/or 

recommendations for IMPEP since its last assessment. 

D. To establish the responsibilities of the individuals and organizations involved in 

the IMPEP self-assessment process. 

III. BACKGROUND

In 1996, the U.S. Nuclear Regulatory Commission (NRC) started implementation of 

IMPEP as a means of evaluating NRC's nuclear materials program activities and 

Agreement State radiation control programs. The NRC developed IMPEP to evaluate 

NRC and Agreement State programs to determine that the programs adequately protect 

public health and safety and determine whether the Agreement State program is 

compatible with NRC’s program. The Office of Federal and State Materials and 

Environmental Management Programs (FSME) currently manages IMPEP. 

Management Directive (MD) 5.6, Integrated Materials Performance Evaluation Program 

(IMPEP) provides the overall structure and framework for the IMPEP process and 

describes the review criteria. NRC developed this procedure in response to the first 

IMPEP assessment in 2001, the 2009 NRC Inspector General audit, OIG-09-A-08, Audit 

of NRC’s Agreement State Program, and the 2010 IMPEP self-assessment. The OIG 

audit identified the need of increased management monitoring of IMPEP operational 

issues and recommended the development of a mechanism to conduct 

self-assessments and capture lessons learned for IMPEP on a regular basis. 
SA-123: Conducting Self-Assessments of the 

Integrated Materials Performance Evaluation 

Program (IMPEP)

Page: 2 of 7 

Issue Date: 

6/24/2011 

The working group that conducted the IMPEP self-assessment in 2010 used a 

methodology similar to the one used by the 2001 IMPEP lessons learned working group, 

and developed a draft procedure to conduct future self-assessment which served as the 

basis to this procedure. 

IV. ROLES AND RESPONSIBILITIES

A. Director, Division of Materials Safety and State Agreements (MSSA), FSME: 

1. Ensures future IMPEP self-assessments are captured in the Division’s 

Operating Plan and the ticket tracking system to ensure IMPEP 

self-assessments are conducted at its suggested frequency; 

2. Determines the scope of the self-assessment review; 

3. Determines whether a MD 5.3, Agreement State Participation in Working 

Groups, NRC/Agreement State working group will be formed, based on the 

scope of the review, or selects a specialized team to review specific aspects 

of the IMPEP process; 

4. Reviews and approves the working group charter and assigns an individual to 

lead this task; 

5. Provides staffing and resource support to the team or working group 

members including coordination and confirmation of necessary support from 

NRC Regional Offices and the Agreement States; and 

6. Makes prioritization and resource decisions on implementation of IMPEP 

self-assessment recommendations. 

B. Chief, Agreement State Program Branch (ASPB), FSME: 

1. Promotes self-assessments timely completion by making available staff and 

resources throughout the review; 

2. Coordinates with MSSA Director the schedule and scope of future 

assessments; 

3. Reviews IMPEP self-assessment draft report for accuracy; and 

4. Ensures that recommendations accepted and endorsed by the MSSA 

Division Director are acted upon in a timely manner. 
SA-123: Conducting Self-Assessments of the 

Integrated Materials Performance Evaluation 

Program (IMPEP)

Page: 3 of 7 

Issue Date: 

6/24/2011 

C. IMPEP Project Manager, ASPB: 

1. Assists the self-assessment working group by providing and making available 

resources and experienced staff with IMPEP; and 

2. Modifies procedures, training programs, or other IMPEP activities, as 

appropriate. 

D. Regions, Division of Nuclear Materials Safety: 

Provides staffing support for the IMPEP self-assessment team or working group. 

E. Organization of Agreement States (OAS) Executive Board: 

Designates the OAS member to work with the IMPEP Project Manager to provide 

staffing support for the IMPEP self-assessment working group. 

F. Working Group Chair/Co-Chair: 

Refer to MD 5.3, for the Working Group Chair/Co-Chair responsibilities. 

G. Working Group Members: 

Refer to MD 5.3 for the Working Group member’s responsibilities. 

V. GUIDANCE

A. IMPEP Self-Assessments 

1. A MD 5.3 working group should be formed to perform IMPEP 

self-assessment every 5 years in order to ensure Agreement State viewpoints 

are sought during the assessment and reflected in working group 

recommendations. 

2. This interval may be adjusted if: 

a. FSME management determines the program is strong enough to sustain 

a longer interval; 

b. IMPEP weaknesses are identified by NRC staff, the Office of the 

Inspector General, the U.S. Government Accountability Office, Agreement 

States, or others that would suggest the need for a tighter review interval; 

or 
SA-123: Conducting Self-Assessments of the 

Integrated Materials Performance Evaluation 

Program (IMPEP)

Page: 4 of 7 

Issue Date: 

6/24/2011 

c. Workload or resource restraints indicate to FSME management, based on 

health and safety considerations, that resources and efforts involved to 

conduct the IMPEP self-assessment are needed to perform a different 

task. 

3. If a weakness(es) is identified in a particular area in between routine IMPEP 

self-assessments and FSME management determines the identified 

weakness(es) does not warrant a complete review of IMPEP, the MSSA 

Division Director may assign a team or an individual to assess particular 

aspects of IMPEP instead of forming a MD 5.3 working group. 

B. Scheduling IMPEP Self-Assessments 

1. IMPEP self-assessments must be captured in MSSA’s Operating Plans and 

tracked in one or more agency tracking systems, such as the Electronic 

Document and Action Tracking System (EDATS) or FSME ticket tracking 

system, to ensure assessments are conducted at the assigned frequency. 

2. MSSA is responsible for providing resources and personnel necessary to 

conduct the self-assessment every five years, unless otherwise specified in 

the previous section. 

C. Assignment of Personnel for IMPEP self-assessments 

1. The working group should be comprised of three to five members, who will 

provide an unbiased analysis of IMPEP with representation from FSME, 

Regional Offices, and Agreement States in order to obtain a variety of 

viewpoints and perspectives. 

2. Working group members should have some level of first-hand IMPEP 

experience, preferably recent, as either a member of the Management 

Review Board (MRB), an IMPEP team leader, IMPEP team member, and/or 

Agreement State or Regional person from a materials program reviewed 

under IMPEP. 

D. Scope of Self-Assessment Review 

1. The working group will conduct its review based on a charter that has been 

prepared and approved by MSSA, in accordance with MD 5.3. 

2. The charter will specify the level of effort and duration of the review 

depending on the scope of the assessment, although the expectation is that 

self-assessments be both thorough and complete. 
SA-123: Conducting Self-Assessments of the 

Integrated Materials Performance Evaluation 

Program (IMPEP)

Page: 5 of 7 

Issue Date: 

6/24/2011 

3. The routine self-assessment should include, at minimum, the following 

components: 

a. Interviews with IMPEP Stakeholders 

i. A representative cross-section of IMPEP stakeholders must be 

interviewed to determine their views on IMPEP effectiveness, 

efficiency, strengths, and weaknesses. 

ii. The working group member(s) assigned to conduct interviews may 

use the sample questions provided in Appendix A as a benchmark to 

ensure open and proactive discussions with IMPEP stakeholders. 

iii. This cross-section should include senior NRC managers who have 

first-hand IMPEP experience, such as Management Review Board 

(MRB) participants, IMPEP Team Leaders, Regional State 

Agreements Officers, IMPEP team members, past and current IMPEP 

Project Managers, MSSA Management, Regional and State 

participants, especially those whose programs were recently reviewed 

under IMPEP.

iv. If possible, a minimum of 15 interviews should be conducted ensuring 

representation of each of the stakeholders mentioned above. 

b. Observation of IMPEP Training 

i. A working group member(s) should observe the IMPEP training 

provided to new IMPEP members in order to assess the effectiveness 

of the training as a means of conveying the IMPEP philosophy and its 

lessons learned to new members, and to prepare them to conduct 

their IMPEP duties. 

ii. The working group should also observe the IMPEP team leader 

training or assess team leaders’ preparation to conduct an IMPEP 

review in an Agreement State or a Regional Office. 

c. Observation of IMPEP Teams during Onsite Activities 

i. Without interfering upon the duties of the IMPEP team, or the program 

under IMPEP review, working group member(s) should observe at 

least two onsite IMPEP reviews. 

ii. If possible, working group member(s) should be able to observe at 

least one Regional IMPEP and one Agreement State IMPEP. 
SA-123: Conducting Self-Assessments of the 

Integrated Materials Performance Evaluation 

Program (IMPEP)

Page: 6 of 7 

Issue Date: 

6/24/2011 

d. Review of IMPEP Documentation 

i. This includes a review of: 

1. MD 5.6; 

2. Representative sample size of IMPEP reports and periodic 

meetings summaries; 

3. IMPEP internal agency and Agreement States correspondence; 

4. State Agreements procedures related to IMPEP activities; and 

5. Previous IMPEP self-assessments. 

E. Documenting IMPEP Self-Assessment Findings 

1. The self-assessment working group will document its results in the form of a 

written report to the MSSA Division Director or his/her designee. 

2. The written report must include, at minimum: 

a. Objectives and the scope of the work assigned; 

b. A description of the methodology used to accomplish the working group 

tasks; and 

c. Working group’s findings and recommendations. 

3. The working group should take into account the practicality of its 

recommendations with respect to the resources that may be required to 

implement its findings. 

4. The working group will provide MSSA Division Director or his designee a draft 

report for factual review. 

5. The working group will issue a final report addressing any factual error or 

misstatements identified by MSSA Division Director or his designee. 

F. Special MRB 

If deemed necessary, MSSA Division Director may request to schedule a special 

MRB to discuss and seek guidance from the MRB on working group 

recommendations and/or implementation. 
SA-123: Conducting Self-Assessments of the 

Integrated Materials Performance Evaluation 

Program (IMPEP)

Page: 7 of 7 

Issue Date: 

6/24/2011 

G. MSSA Response and/or Actions Based on Working Group Recommendations 

1. Any recommendations that have been accepted and endorsed by MSSA 

management will be tracked to completion in one or more agency tracking 

systems such as EDATS, FSME or Division tracking systems. 

2. The responsibility for implementing any working group recommendation rests 

within FSME and not in the working group itself, unless otherwise specified in 

the charter. 

VI. APPENDICES

Appendix A – Sample Questions to Conduct IMPEP Self-Assessment Interviews 

VII. REFERENCES

1. Final Working Group Report for the IMPEP Lessons Learned Working Group

(ML021980296). 

2. OIG-09-A-08, Audit of NRC’s Agreement State Program – March 16, 2009 

(ML090750622). 

3. Self-Assessment of the Integrated Materials Performance Evaluation Program 

(IMPEP) (ML102030228). 

4. NRC Management Directive 5.3, Agreement State Participation in Working Groups. 

5. NRC Management Directive 5.6, Integrated Materials Performance Evaluation 

Program (IMPEP). 

VIII. ADAMS REFERENCE DOCUMENTS 

For knowledge management purposes, all previous revisions of this procedure, as well 

as associated correspondence with stakeholders that have been entered into ADAMS 

are listed below. 

No. Date Document Title/Description Accession Number

1 1/21/11 FSME-11-010, Opportunity to Comment on Draft 

Revisions to FSME Procedure SA-123 

ML103630011 

2 1/21/11 FSME Draft Procedure SA-123 ML103620765 
 Appendix A

Sample Questions to Conduct IMPEP Self-Assessment Interviews 

1. In general, what is your assessment or appraisal of the effectiveness and efficiency of 

IMPEP? 

2. How might either of these dimensions be improved? For example, how might NRC 

better employ Information Technology to improve efficiency and effectiveness, 

particularly of the onsite portion of the review? 

3. Do the current performance indicators suffice for evaluating Regional and Agreement 

State programs? Do they adequately capture the attributes of a high performing 

organization? Would you recommend any new indicators or would you make any 

changes to the existing indicators? If so, why? 

4. How might the concurrence/review process for IMPEP reports be improved? Should the 

format of the reports be changed (e.g., more bullets, less boilerplate text)? 

5. Should the frequency for IMPEP reviews remain at the current 4 year interval or should it 

be changed? Why? 

6. How effective are the periodic meetings between IMPEP reviews? 

7. What issues have arisen from IMPEP/MRB reviews that were most difficult to deal with? 

8. What changes, if any, would you make to the IMPEP training program? 

9. Is NRC selecting the right candidates to serve as team members and team leaders from 

the Agreement States, Regions, and Headquarters? 

10. How is the MRB process working? Does it appear to be meeting the purpose that it was 

intended to serve? 

11. Are the overall findings from the IMPEP process in terms of indicators and conclusions 

still appropriate? Do we need additional steps? 

12. Are there additional NRC programs that need to be included under the umbrella of 

IMPEP, such as Uranium Recovery licensing in Headquarters? (Applicable to NRC 

personnel.) 

13. What are your thoughts about the resource burden imposed by IMPEP? Is it justified? 

Which aspects of the program are particularly resource intensive? Do you consider 

there are better alternatives? 
Appendix A Page 2 

14. What should our expectations be about availability of staff during the onsite week of an 

IMPEP review? 

15. Should our indicator on Technical Quality of Inspections place greater weight on 

accompaniments, as opposed to review of files? 

16. What are your thoughts about the monitoring or heightened oversight processes 

(particularly important for Agreement States that have been under monitoring or 

heightened oversight)? 

17. The pre-review questionnaire is a central part of the IMPEP process. Does it continue to 

make sense, especially in light of resource constraints? What alternatives are there to 

accomplish the same objective? Are the time constraints for receipt, preparation and 

submittal of the questionnaire reasonable? 

18. Is there anything else about IMPEP that you would like to discuss?