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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1195">Follow-up when Effectiveness Reviews identify Actions were Partially-Effective - Oak Ridge National Laboratory (ORNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>When an assessment identifies that corrective actions were only partially effective, conduct further analysis to determine what additional actions are needed to effectively resolve the condition. Track the identified actions using ORNL's Assessment and Commitment Tracking System (ACTS).</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Between July and September 2021, the Oakridge Protection Division conducted a self-assessment of the Incident of Security Concern (IOSC) Program. The assessment included review of past corrective actions, and tracking and closure results from past reviews. The assessment identified two effectiveness reviews that were determined to be partially effective, however, there was no evidence that any follow-up action was taken to correct the situations, and no additional actions were identified to bring the conditions into full compliance.
Issues management procedures require that when an effectiveness review determines corrective actions produced inadequate results, the Performance Analysis & Quality Manager, Issue Owner and Effectiveness Review Lead are to work together to determine a path forward. Critiques, investigation, causal analysis, effectiveness review, and other relevant information are to be utilized to development additional actions. The Issue Owner is then required to develop a corrective action plan (CAP) with additional corrective actions that are then tracked through ACTS.
If appropriate, the new/revised CAP is reviewed by the ORNL Corrective Action Institutional Review Board, prior to finalization, to ensure corrective actions will achieve desired results.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>? When corrective actions do not fully resolve identified conditions, it is unlikely the action will be sustainable over time.
? Partially effective corrective actions can contribute to recurrence of similar, or more significant issues.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>ORNL's Performance Analysis & Quality Department will continue to monitor the IOSC effectiveness reviews to ensure conditions are adequately resolved by identified corrective actions.
As a valuable tool for continual performance improvement, and to encourage effectiveness of process implementation/execution, feedback will be solicited on the effectiveness of the review?s corrective actions.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">11/10/2022 12:20:54 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in
MGT101: Basic Jlab supervisor/manager knowledge</pre>
</div>
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<div class="yui-u" id="lesson_info">
<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1195</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
</tr>
<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2022-JLAB-1195</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</td>
</tr>
<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">11/10/2022 12:13:47 PM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">11/10/2022 12:20:54 PM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">ORNL</td>
</tr>
<tr class="row">
<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
</tr>
<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Jill Christian, ORNL Performance Analysis & Quality Division Director </td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">291</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">1 times</td>
</tr>
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<legend>Attachments</legend>
<a name="attachments"></a>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6726">OPEXShare ORNL - Effectiveness Reviews.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Other: Human Performance Improvement</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>MGT101: Basic Jlab supervisor/manager knowledge</li>
</ul>
</fieldset>
<fieldset>
<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
</ul>
</fieldset>
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