The MSV process developed by ACC is a tool (not a requirement) that DOE sites may consider to help determine whether their ES&H program is truly integrated into all work at all levels by all employees. The use of the process is strictly voluntary and at the discretion of the DOE sites who, if they decide to use this process, may use it: 1) informally and internally without peers from other sites or community representatives; in which case, it would a form of self-assessment; or, 2) formally with external involvement including peers and community reps.
BACKGROUND
In 1993 the American Chemistry Council (ACC) Board of Directors recommended a process be developed to verify the management system of their Responsible Care® program. The Board stated that this verification process would assist ACC companies in improving their ES&H performance and contribute to the building of trust between chemical facilities and their neighboring communities. After three years of development and testing, ACC companies began using the process in 1996, and more than three dozen companies have now completed the Management System Verification (MSV) process. Although the results are given only to the company, many companies have publicized their results. For example, the Rohm and Haas Company has their MSV report on the Internet at http://www.rohmhaas.com/company.dir/MSV.
DESCRIPTION
The MSV process:
- verifies that appropriate systems are in place and functioning to assure continued compliance with applicable regulations;
- verifies that appropriate ES&H performance goals have been established;
- looks for internal company audit procedures to verify ongoing compliance with company goals and external regulations;
- is NOT an audit to identify non-compliance with local, state, or federal regulations;
- does NOT validate the adequacy of ES&H performance such as the level of air or water emissions at a facility.
The ACC MSV process is built around a verification protocol, or guidance document, which organizes the verification into a general sequence of steps. The protocol identifies organizational structures, responsibilities, practices, procedures, processes and resources for implementing and maintaining a management system which are then reviewed by a team of verifiers. In the ACC process, industry peers accompanied by community representatives, engage in a series of open-ended interviews of company personnel, documentation reviews, and on-site observations to determine whether a company has appropriate, functioning, and sustainable management systems in place. Through this interview/review/observation process, the industry peers and community reps are able to identify strengths and areas for improvement in the company's management systems. These findings are submitted to the company being verified (and ONLY to the company being verified) in a final written report.
The protocol organizes the verification into a general sequence of steps covering five core areas:
- Policy and Leadership;
- Planning;
- Implementation, Operation, and Accountability;
- Performance Measurement and Corrective Action; and
- Management Review and Reporting. These core areas are essentially the five major steps in a Work Management System used for all work including ES&H as an integral part.
"Attributes" have been identified within each of the five core areas. Attributes are the necessary systems, organization, policies, programs, etc. that support each core area of the management system and are the basis for the evaluation of the overall management system. Evidence of the existence of these attributes and their integration into the company's operations and culture should result in effective management systems. Sample interview questions have been developed to determine the existence and integration of the attributes.
MANAGEMENT SYSTEMS VERIFICATION PROCESS STEPS
A procedure for carrying out a management systems verification could include the following steps:
- Site contractor Executive Contact volunteers for a management systems verification by notifying the DOE, EH-53, Office of Field Support.
- Verification team leader and members are selected from a pool of trained individuals.
- Supporting ES&H contractor identified.
- The team leader (with support of the identified contractor) contacts site contractor's ES&H Manager requesting information about the company and supporting documentation (define info and docs).
- Team Leader (with the support of the identified contractor) and the site contractor's ES&H Manager will determine the scope and conduct of the verification, review the list of individuals to be interviewed, and determine which facilities will be visited by the team. Upon request, the site contractor will provide to the team names of appropriate second-and third-party contacts (carriers, distributors, subcontractors, community representatives) for possible interviews.
- A site contractor/verifier legal agreement covering protection of confidential business information and indemnification of the participants is signed.
- Site contractor identifies appropriate public representatives who will accompany the verification team on its visit. These individuals are selected by the site contractor through its local dialogue process.
- The team leader will contact the public representatives to ensure that they are aware of their selection and understand the verification process. DOE, EH-53 will provide the company with a verification orientation kit for distribution to each community participant.
- The verification begins with the team's visit to the site contractor's headquarters to interview the executive contact and senior staff
- Team visits selected facilities/operations to interview manager and appropriate staff. During the site visit, the team conducts a plant tour.
- Team conducts closing meeting with ES&H Manager and/or appropriate staff at each level of the process.
- The team develops its final narrative report. A draft of the report is sent to the site contractor and area office factual review. Only the site contractor and area office receives a copy of the final report.
- Each team member will certify that all work papers and related information are collected and destroyed. All documents supplied to the team will be returned to the site contractor.
- DOE HQ issues recognition of participation to company.
MANAGEMENT SYSTEMS VERIFICATION
Protocol
Management Systems Verification is designed to support an organization's efforts to improve their responsible management of DOE facilities. The core elements of the Management System are defined below and are shown in the following figure of an Integrated Work and ES&H Management System. The core elements and their Attributes and Verifier Questions are subsequently described.
Policy and Leadership
This management element addresses the leadership exhibited by senior management in setting clear policy and guidelines for performance, and for enhancing the value of the ES&H ethic within the organization.
Planning
This management element addresses; 1) the identification and assessment of relevant regulations and industry standards, 2) the evaluation of product, process and distribution risks, 3) the identification and assessment of employee and community concerns about the organization's environmental, health and safety performance, and 4) setting priorities and goals for performance improvement.
Implementation, Operation, and Accountability
This management element addresses the achievement of objectives and policy expectations. It also covers the preparation and competence of employees to carry out their tasks, and documentation that is critical to the execution of those tasks.
Performance Measurement and Corrective Action
This management element deals with the use of performance indicators, performance reviews, accident and incident investigation, compliance audits, data records, and taking or recommending corrective actions.
Management Review and Reporting
This management element addresses the manner in which the organization reports its performance to its stakeholders and senior management, and how the organization and senior management reviews that performance relative to goals and makes appropriate changes in goals, policies or priorities.
The Department of Energy and its contractors are committed to support a continuing effort to improve the responsible management of DOE facilities. They pledge to manage their operations accordingly, placing a high priority on the protection of the environment, and health and safety of their employees and the public, and the implementation of sound ES&H management practices. To do so effectively their environmental, health and safety activities must be conducted within a structured system that is integrated with their overall management activity. The core elements of a ES&H management system are described below:
CORE ELEMENTS OF ES&H MANAGEMENT SYSTEM
- POLICY AND LEADERSHIP
This management element addresses the leadership exhibited by senior management in setting clear policy and guidelines for performance, and for enhancing the value of the ES&H ethic within the organization.
Attributes
Senior management demonstrates leadership and commitment for their organization (company, plant or business unit) by active participation in the creation and implementation of a clear and visible policy that:
- is relevant to the nature and scale of the organization's products and processes,
- fosters openness in dealing with stakeholders and takes into account public and employee inputs,
- includes a commitment to continual improvement of the management of ES&H and sets a framework for reviewing and establishing ES&H objectives and targets,
- includes a commitment to comply with relevant legislation and regulations,
- reflects the company's commitment to the principles of integrated safety management,
- is documented, maintained and communicated to employees, and
- provides adequate staffing and resources for the proper implementation of the policy and the ES&H program.
Senior management enforce the policy to the point that they:
- view a successful ES&H program as a personal achievement
- include ES&H program as a key component in their strategic plan
- regularly discuss commitment to continuous improvement of ES&H both internally and externally
- make sure that their CEO and Board of Directors understands the ES&H program and receives regular reports
- require all employees to establish ES&H goals and then evaluated employees on these goals
- require management systems to be established to support ES&H and to be updated and improved as needed
- participate in peer groups (i.e., DOE's Executive Leadership Groups) designed to share ideas, goals, etc., and require other company managers (line and staff) to participate in similar groups
- require specific plans with timetables for implementing ES&H programs and they personally review progress of the plans
- require regular messages about ES&H programs in site newsletters, quarterly reports, annual reports, etc.
- compare their company's ES&H performance against other DOE contractors of similar size
- PLANNING
The management element addresses; 1) the identification and assessment of relevant regulations and industry standards, 2) the evaluation of product, process and distribution risks, 3) the identification and assessment of employee and community concerns about the organization's environmental, health and safety performance, and 4) setting priorities and goals for performance improvement.
Attributes
The organization demonstrates appropriate planning by:
- having processes in place for the assessment of hazards and risks associated with their products, processes and distribution activities that includes impact on the environment, personnel and communities,
- integrating the risk evaluation process into the research and development of new products and processes,
- creating and maintaining a product information system related to environmental, health and safety risks,having processes in place for the systematic review of all environmental, health and safety related regulations, and their interpretations, that are relevant to the organization's activities,
- maintaining documented ES&H objectives and targets which have clear means, time frames, and responsibilities for accomplishment,
- having a system in place for the identification of needs and allocation of resources to implement performance improvements, and
- having processes in place to assess community and employee concerns about the organization's activities.
- IMPLEMENTATION, OPERATION AND ACCOUNTABILITY
This management element addresses the achievement of objectives and policy expectations. It also covers the preparation and competence of employees to carry out their tasks, and documentation that is critical to the execution of those tasks.
Attributes
The organization demonstrates that implementation, operation and accountability are part of their management system by the existence of:
- a clear definition of responsibility and accountability for the execution of ES&H tasks,
- training programs that include task specific skills and competencies, and awareness of regulatory requirements appropriate to the task,
- a process for communication and dialogue with stakeholders of relevant risks and impacts of the organization's activities to human health and the environment, and plans for improving the organization's ES&H management system,
- employee involvement in the development, communication and execution of ES&H programs,
- documented procedures to ensure safe operations for all processes, process changes, maintenance, and product handling and storage,
- written site emergency response plans with appropriate considerations of communications and community recovery needs.
- participation in the development of community emergency preparedness planning,
- a documented process for responding to chemical distribution incidents,
- programs to provide appropriate guidance, information and training requirements to carriers, distributors, customers and contractors on the risks and hazards of the organization's products and processes, and for receiving guidance and information from suppliers on goods and services used by the organization,
- processes for the qualification and selection of carriers, distributors and contractors that place priority on safety performance, and
- clearly defined and visible emissions reduction, pollution prevention, and ground water protection programs.
- PERFORMANCE MEASUREMENT AND CORRECTIVE ACTION
This management element deals with the use of performance indicators, performance reviews, accident and incident investigation, compliance audits, data records, and taking or recommending corrective actions.
Attributes
The organization demonstrates the use of performance measurement and corrective action by having processes in place for:
- the tracking of emissions and releases, accidents and injuries, process upsets, and distribution incidents,
- reviewing the performance of all carriers, suppliers, distributors, customers and contractors,
- the investigation of accidents and incidents that get at the root causes of occurrence and develop recommendations for prevention or corrective action,
- the maintenance of sufficient data files to enable analysis of trends and performance against goals,
- the audit or review of compliance with regulations and company procedures, and
- the measurement of the effectiveness of its communications programs with its stakeholders.
- MANAGEMENT REVIEW AND REPORTING
This management element addresses the manner in which the organization reports its performance to its stakeholders and senior management, and how the organization and senior management reviews that performance relative to goals and makes appropriate changes in goals, policies or priorities.
Attributes
Management Review and Reporting are characterized by evidence of:
- periodic reviews of the organization's objectives and policies for relevance against the organization's products and processes, the expectations of stakeholders, the adequacy of resources assigned to ES&H management programs, and the organization's performance against their goals and policies,
- reporting mechanisms to stakeholders, employees and communities on the organization's ES&H results,
- bench marking of ES&H management systems against other organizations, and
- a performance management system for employees that recognizes ES&H excellence.
QUESTIONS FOR VERIFYING THE MANAGEMENT SYSTEM
Sufficient dialogue must take place between the verifiers and the appropriate managers of the organization to determine whether the elements of the management process have been developed, integrated into the organization's activities and are effective in improving performance. Questions should be asked to directly probe the significant management process element attributes.
Sample questions, listed below are designed to open dialogue. Bullet items under the questions are thoughtful probes to lead to further questions if the necessary information is not forthcoming in the dialogue resulting from the questions. In some cases the thoughtful probes define questions to be asked of different functional managers within an organization. There is also listed the most appropriate attribute that corresponds to the question and some suggested actions for the verifiers to go through that can enhance the information gathering process.
Questions for Senior Management to test Policy and Leadership
The verifiers should obtain copies of appropriate policies and publications that contain policies prior to the interviews. They should look for such things within the policies such as references to industry ES&H initiatives such as ISO 14001, legal compliance or continual improvement. The verifiers should be very familiar with the policies prior to the interviews.
- What process have you gone through to determine if your ES&H policy is relevant to the nature of your organization ‘s business and takes into account public and employee inputs? (Attribute A.1 and A.2)
- Reviewed against industry peers?
- Have board level review?
- Make results based judgments?
- Have employee committees?
- How do you integrate the philosophy of continual improvement into your ES&H policy and set a framework for establishing objectives? (Attribute A.3)
- Set long term goals?
- Integrate quality and business management with ES&H management?
- Make explicit references?
- How do you encompass the range of regulatory requirements and their compliance in your policy? (Attribute A.4) (If done through explicit wording in policy this does not have to be asked)
- How have you worked the principles of integrated safety management (Attribute A.5) (If done through explicit wording in policy this does not have to be asked)
- Could you describe your process for communicating your policy to employees? (Attribute A.6)
- Periodic reports?
- Newsletters, bulletin boards?
- Could you describe you process for identifying the resources needed and staffing required for ES&H implementation and how you test the adequacy of the resources allocated? (Attribute A.7)
- Bottom up?
- Review with peers?
- Could you describe your personal role in the communication of your commitment and dedication to ES&H (Opening paragraph)
- Speeches?
- Periodic messages to employees?
- Industry participation?
Questions for Appropriate Managers in the Organization to Test Planning
It is not practical to review many documents or manuals prior to these interviews. However, any brochures, pamphlet, or other publication that describe the company's product information system should be reviewed prior to the interviews. Interviewees should be encouraged to use examples and provide samples of manuals, etc. during the interviews for reference and illustration.
- Could you describe your process for assessing product and process risks and how you integrate it into new research and development? (Attribute B.1 & B.2)
- Methodology?
- Distribution?
- Inbound materials?
- What kind of system do you maintain for product and process risk data and what type of data is in the system? (Attribute B.3)
- Computer based?
- On-line?
- Toxicology?
- Regulatory classifications?
- How does your organization identify the regulations, legislation and interpretations that are relevant to your operations (Attribute B.4)
- EPA?
- OSHA?
- DOT?
- Other government agencies?
- Trade association activity?
- How are your ES&H goals and targets maintained and kept current? (Attribute B.5)
- Specified performance targets?
- Time frame expectations?
- Could you describe how you identify staffing and resource needs for implementation of ES&H programs (Attribute B.6)
- Bottom up?
- Peer review?
- How do you identify and assess employee and community needs? (Attribute B.7)
- Community Advisory Panels?
- Surveys?
- Focus Groups?
Questions for Appropriate Managers in the Organization to test Implementation, Operation and Accountability
Pre-review of documents and manuals is not practical for this set of interviews. Manuals and documents should be made available for casual review by the verifiers and to be used for illustration and example during the interviews. In this portion of the interviews performance data may be used to assist in the illustration of programs.
- Could you describe the way your organization is structured to implement the ES&H program (Attribute C.1)
- Responsibility matrix?
- Accountability?
- Could you describe your organization's training programs? (Attribute C.2)
- Job Skills?
- Environmental, health and safety training?
- Competency requirements?
- Training records?
- Regulatory familiarization?
- Could you describe your communications and outreach programs (Attribute C.3)
- With employees?
- With communities?
- With stockholders?
- With customers?
- With carriers and contractors?
- How do you get employees to contribute to the outreach and communications programs? (Attribute C.4)
- Volunteers?
- Delegation?
- Training?
- How are your ES&H requirements built into your process operating procedures(Attribute C.5)
- Regular HAZOPS?
- Regular Job Safety & Health Analysis (JSHA)?
- Review committees?
- Employee involved?
- Could you describe your emergency response plans and your involvement with community preparedness planning? (Attribute C.6,7 &8)
- For plant sites?
- For distribution?
- LEPC involvement?
- Testing of plans?
- Integration with the community and neighbors?
- What is your process for providing and receiving risk-related guidance and information to/from your commercial partners (Attribute C.9)
- Distributors?
- Customers?
- Contractors?
- Suppliers?
- Could you describe your process for qualifying and selecting suppliers of services and materials to your organization? (Attribute C.10)
- Pre-screening audits?
- Qualification criteria?
- Carriers?
- Toll processors?
- Subcontractors?
- Distributors and terminals?
- Disposal sites?
- Can you describe your emissions reduction, pollution protection and ground water protection program? (Attribute C.11) (The use of results and performance data in the form of graphs and tables may be used as an appropriate tool for describing the programs)
- Goals and targets?
- Stage of implementation?
Questions for the Appropriate Managers in the Organization to test Performance Measurement and Corrective Action
Performance data must be used in this portion of the interviews to demonstrate the tracking processes. (Care must be exercised by the verifiers to look only at the tracking process and not the level of performance.)
- Could you describe your process for tracking ES&H performance? (Attribute D.1)
- Injury and illness?
- Process incidents?
- Distribution incidents?
- Toxic releases?
- Regulatory violations?
- How do you track the performance of your commercial partners and review it with them? (Attribute D.2)
- Subcontractors?
- Customers?
- Distributors?
- Could you describe your accident/incident investigation processes? (Attribute D.3)
- Injury and illness?
- Distribution?
- Process incidents?
- Near-hits?
- Root causes?
- Corrective action?
- Do you maintain a data base of all accidents, incidents and near-hits to facilitate analysis of trends? (Attribute D.4)
- Injury and illness?
- Distribution?
- Process incidents?
- Customer reports?
- Could you describe your internal audit processes for measuring compliance with regulations and your organization's policies? (Attribute D.5)
- OSHA?
- EPA?
- TSCA?
- DOT?
- Other government agencies?
- How do you measure the effectiveness of your communications and outreach programs? (Attribute D.6)
- Surveys?
- Focus groups?
Questions for Senior Management and Appropriate Manages of the Organization to test Management Review and Reporting
This portion of the interviews does require pre-review of environmental reports, annual reports, newsletters, etc.
- What process does your organization use to periodically review your ES&H policy for relevance and appropriateness? (Attribute E.1) (This question may be redundant if adequate answers were provided in the interviews involving policy and planning)
- Board review?
- Senior management review?
- Bench marking?
- How does your organization review and discuss your ES&H performance? (Attribute E.1)
- Management Council?
- Department meetings?
- How do you determine if the resources applied to implementation of you policy and attainment of your objectives is adequate? (Attribute E.1)
- Results?
- Board review?
- Bench marking?
- Could you describe your processes for reporting your ES&H results to your stakeholders and communities? (Attribute E.2)
- Employees?
- Stockholders?
- Plant communities?
- Public?
- Could you describe some of your bench marking activities within the industry? (Attribute E.3)
- Managed systems?
- Performance?
- Have you included ES&H performance in your employee performance management process? (Attribute E.4)
- MBO/KRAs?
- Bonuses?
- Merit increases?
- Special forms of recognition?
- Job description and annual reviews?